Utilization Case Manager RN (H)

Current Employees: If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this tip sheet. CORE JOB SUMMARY The purpose of the Utilization Case Manager RN is to conduct initial chart reviews for medical necessity and identify the need for authorization. The Utilization Case Manager RN coordinates with the healthcare team for optimal and efficient patient outcomes, while avoiding potential 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 as it pertains to treatment or treatment barriers. Finally, the nurse serves as the subject matter expert to her team, providing support and education. CORE JOB FUNCTIONS 1. Adhere and perform timely prospective reviews for services requiring prior authorization 2. Follows the authorization process using established criteria as set forth by the payer or clinical guidelines 3. Accurate review of coverage benefits and payer policy limitations to determine appropriateness of requested services 4. Refers to the treatment plan for clinical reviews in accordance with established criteria in recommended compendia and or guidelines 5. Serves as a resource to provide education regarding payer policies and facilitates coordination of alternative treatment options 6. Ensures and maintains effective communication regarding prior authorization status and determination to the clinical team and on occasion the patient. 7. Facilitates interdepartmental communication regarding authorization status in advance of the patient's appointment 8. Identifies potential delays in treatment by reviewing the treatment plan and proactively communicates with the healthcare team and or patient regarding the potential treatment barrier 9. Maintains knowledge regarding payer reimbursement policies and clinical guidelines. 10. Adheres to University and department level policies and procedures and safeguards University assets. 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. CORE QUALIFICATIONS Education: Bachelor's degree in Nursing Certification and Licensing: Registered Nurse License; Basic Life Support Certification (BLS). Core_Utilization Case Manager RN Experience: Minimum 2 years of relevant experience Knowledge, Skills and Attitudes: Ability to exercise sound judgment in making critical decisions. Skill in completing assignments accurately and with attention to detail. Ability to analyze, organize and prioritize work under pressure while meeting deadlines. Ability to work independently and/or in a collaborative environment. Ability to communicate effectively in both oral and written form. 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. The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Job Status: Full time Employee Type: Staff 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 of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.