Utilization Case Manager

This is a fully remote position, open to applicants in Florida.

📋 Description

• Conduct routine evaluations for clinical utilization and assess the need for ongoing authorization.

• Collaborate with the Nurse Case Manager and healthcare team to achieve optimal patient outcomes.

• Oversee a specified patient caseload and ensure that the criteria for continued authorization are upheld.

• Execute timely evaluations for services that necessitate authorization for ongoing care.

• Adhere to authorization procedures by utilizing established payer criteria or clinical guidelines.

• Analyze coverage benefits and limitations to determine the ongoing appropriateness of requested services.

• Enhance interdepartmental communication regarding the status of continued authorization prior to patient appointments.

• Relay authorization status and decisions to clinical teams and patients effectively.

• Detect potential treatment delays by examining treatment plans and proactively addressing treatment obstacles.

• Maintain up-to-date knowledge of payer reimbursement policies and clinical guidelines.

• Comply with University and departmental policies and procedures while safeguarding University assets.

⛳️ Requirements

• Bachelor’s degree in a relevant field; or equivalent experience.

• A minimum of 2 years of pertinent experience.

• Familiarity with payer reimbursement policies and clinical guidelines.

• Capability to follow authorization procedures using established payer criteria or clinical guidelines.

• Proficiency in reviewing coverage benefits and limitations.

• Skill in coordinating with nurse case managers and healthcare teams.

• Ability to effectively communicate authorization status and decisions to clinical teams and patients.

• Competence in identifying potential treatment delays and authorization challenges.

• Commitment to adhering to University and departmental policies and procedures.

🏝️ Benefits

• Competitive salaries.

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