Case Manager RN Utilization Review
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Job Location:
Monthly Salary:
Posted on:
20 hours ago
Vacancies:
1 Vacancy
Job Summary
Current Employees:
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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. The nurse serves as the subject matter expert to her team providing support and education.
Work Location : UHealth Tower
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 patients 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:
Graduate from an accredited school of nursing Bachelors degree (BSN).
Certification and Licensing:
Valid State of Florida RN license required
Basic Life Support Certification (BLS) from the American Heart Association required.
Experience:
Minimum 2 years of relevant experience required. Minimum of one 1 year in Hospital Case Management/nursing.
Working knowledge of patient assessment and medical terminology.
Knowledge Skills and Attitudes:
Learning Agility: Ability to learn new procedures technologies and protocols and adapt to changing priorities and work demands.
Teamwork: Ability to work collaboratively with others and contribute to a team environment.
Technical Proficiency: Skilled in using office software technology and relevant computer applications.
Communication: Strong and clear written and verbal communication skills for interacting with colleagues and stakeholders.
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 Floridas 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. Were the challenge youve 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 timeEmployee Type:
StaffRequired Experience:
Manager
Key Skills
- Project Portfolio Management
- Motivational Interviewing
- HIPAA
- Computer Skills
- Intake Experience
- Lean Six Sigma
- Conflict Management
- Case Management
- Team Management
- Program Development
- Social Work
- Addiction Counseling
