Utilization Case Manager RN (Healthcare)

About the role

The Utilization Case Manager RN at the University of Miami reviews patient charts to determine medical necessity and coordinate prior authorizations. The role ensures timely communication with the clinical team and patients, aiming to prevent treatment delays and authorization denials.

Key responsibilities

• Conduct prospective reviews for services requiring prior authorization.
• Apply payer criteria and clinical guidelines to assess coverage benefits.
• Communicate authorization status and decisions to the clinical team and patients.
• Identify potential treatment barriers and coordinate alternative options.
• Educate staff on payer policies and facilitate interdepartmental communication.
• Maintain up‑to‑date knowledge of reimbursement policies and university procedures.

Required profile

• Bachelor’s degree in Nursing.
• Active Registered Nurse license.
• Basic Life Support (BLS) certification.
• Minimum two years of relevant nursing or case management experience.

Required skills

• Sound clinical judgment for critical decisions.
• Attention to detail in reviewing documentation.
• Ability to prioritize work under pressure and meet deadlines.
• Effective independent and collaborative work habits.

What we offer

• Opportunity to work within a multidisciplinary healthcare team.
• Professional development in utilization management.
• Supportive academic environment.