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The University of Miami is currently seeking Utilization Review Case Manager to work at Sylvester Support Service Building in Miami. The incumbent conducts initial, concurrent and retrospective chart reviews for clinical utilization and authorization. The Utilization Review Case Manager coordinates with the healthcare team for optimal and efficient patient outcomes, while avoiding treatment delays and authorization denials. They are accountable for a designated patient caseload and provide intervention and coordination to decrease avoidable delays, at all times they provide communication of progress and or determination to the clinical team and or the patient. He/she monitors care and acts as a liaison between patient/family, healthcare personnel, and insurers. Evaluates the needs of the patient, the resources available, and recommends and facilitates for the best outcome to meet ongoing patient needs that encourages compliance with medical advice.
Adhere and perform timely prospective review for services requiring prior authorization as well as timely concurrent review for continuation of care services
Follows the authorization process using established criteria as set forth by the payer or clinical guidelines
Accurate review of coverage benefits and payer policy limitations to determine appropriateness of requested services
Refers to the treatment plan for clinical reviews in accordance with established criteria and guidelines
Facilitates communication of denials and or Peer to Peer requests between payers and the healthcare team
Identifies potential delays in treatment or inappropriate utilization by reviewing the treatment plan, serves as a resource to provide education regarding payer policies and assists with coordination of alternative treatment options
Ensures and Maintains effective communication regarding authorization status and determination to the clinical team and on occasion the patient.
Proactive communication with leadership regarding barriers and or potential delays in care Identifies opportunities for expedited requests and prioritizes caseload accordingly
Maintains knowledge regarding payer reimbursement policies and clinical guidelines.
This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.
Bachelor’s degree in relevant field; or equivalent
Minimum of 2 years of relevant experience
Oncology - Preferred
The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.
UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.
Patient safety is a top priority. As a result, during the Influenza ("the flu") season (September through April), the University Of Miami Miller School Of Medicine requires all employees who provide ongoing services to patients, work in a location (all Hospitals and clinics) where patient care is provided, or work in patient care or clinical care areas, to have an annual influenza vaccination. Failure to meet this requirement will result in rescinding or termination of employment.
The University of Miami is an Equal Opportunity Employer - Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Click here (https://www.hr.miami.edu/careers/eo-ada/index.html) for additional information.
The mission of the University of Miami is to transform lives through education, research, innovation, and service. A vibrant and diverse academic and healthcare community, the University of Miami and the University of Miami Health System ("UHealth") have rapidly progressed to become one of the nation’s top research universities and academic medical centers in the nation.
The University comprises 12 schools and colleges serving undergraduate and graduate students in more than 350 majors and programs. Visit welcome.miami.edu/about-um to learn more about our points of pride.
The University ranks No. 55 on U.S. News & World Report’s 2022 Best Colleges list and ranked No. 49 in the 2022 Wall Street Journal/Times Higher Education College Rankings.
Bascom Palmer Eye Institute is ranked the #1 eye hospital in the USA and offers some of the nation's premiere eye doctors to treat every eye condition for adults. Sylvester Comprehensive Cancer, part of the Miller School of Medicine, received the prestigious National Cancer Institute designation in 2019.
The University of Miami and UHealth have also ranked among the Forbes Best Employers and Best Employers for Women on several occasions, most recently in 2022.
With more than 17,000 faculty and staff, the University strives for excellence, and is driven by a powerful mission to transform and impact the lives of its students, patients, members of the community, and people across the globe.
The University is committed to fostering a culture of belonging, where everyone feels valued and has the opportunity to add value. Through values of Diversity, Integrity, Responsibility, Excellence, Compassion, Creativity, and Teamwork (DIRECCT) the U community works together to create an environment driven by purpose, excellence, community, and service.