Oncology Prior Authorization Case Manager, Non-RN

University of Miami•Miami, FL

2d•Remote

About The Position

The Utilization Case Manager (Remote) completes ongoing clinical utilization reviews and identifies the need for continued authorization. The role coordinates with the Nurse Case Manager and healthcare team to support optimal patient outcomes while avoiding treatment delays and authorization denials. The case manager manages a designated patient caseload and ensures that criteria for continued authorization remain in place. The position communicates progress and determinations to the clinical team and, when appropriate, to the patient. The role adheres to University and department policies and procedures and safeguards University assets. The listed duties are not all-inclusive and may be expanded as necessary.

Requirements

Bachelor’s degree in a relevant field.
At least 2 years of relevant experience.

Responsibilities

Complete timely ongoing reviews for services requiring authorization for continuation of care.
Follow the authorization process using established payer criteria or clinical guidelines.
Review coverage benefits and limitations accurately to determine the continued appropriateness of requested services.
Facilitate interdepartmental communication about continued authorization status in advance of the patient’s appointment.
Communicate authorization status and determinations to the clinical team and, on occasion, the patient.
Review treatment plans to identify potential treatment delays and proactively communicate potential barriers to the healthcare team and/or patient.
Maintain knowledge of payer reimbursement policies and clinical guidelines.
Adhere to University and department policies and procedures and safeguard University assets.