[Hiring] Oncology Prior Authorization Case Manager @UOMUOMUS

Role Description

The University of Miami Health System Department of UMHC SCCC Business Operations has an exciting opportunity for a full-time Utilization Review Case Manager to work remotely. 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 providing 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.
• Follow 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.
• Refer to the treatment plan for clinical reviews in accordance with established criteria and guidelines.
• Facilitate communication of denials and/or Peer to Peer requests between payers and the healthcare team.
• Identify potential delays in treatment or inappropriate utilization by reviewing the treatment plan, serve as a resource to provide education regarding payer policies and assist with coordination of alternative treatment options.
• Ensure and maintain 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.
• Identify opportunities for expedited requests and prioritize caseload accordingly.
• Maintain 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.

Qualifications

• Bachelor’s degree in relevant field; or equivalent.
• Minimum of 2 years of relevant experience.
• Oncology - Preferred.
• Any relevant education, certifications and/or work experience may be considered.

Benefits

• Competitive salaries.
• Comprehensive benefits package including medical, dental, tuition remission, and more.

Company Description

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the groundbreaking 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.