Integration Manager
Redox
Oncology Prior Authorization Case Manager, Non-RN
University of Miami
full-time
Posted on:
Location: Florida • 🇺🇸 United States
Visit company websiteJob Level
JuniorMid-Level
About the role
- Adhere and perform timely prospective review for services requiring prior authorization as well as timely concurrent review for continuation of care services
- Follows 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
- Refers to the treatment plan for clinical reviews in accordance with established criteria and guidelines
- Facilitates communication of denials and or Peer to Peer requests between payers and the healthcare team
- Identifies potential delays in treatment or inappropriate utilization by reviewing the treatment plan, serves as a resource to provide education regarding payer policies and assists with coordination of alternative treatment options
- Ensures and Maintains 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
- Identifies opportunities for expedited requests and prioritizes caseload accordingly
- Maintains knowledge regarding payer reimbursement policies and clinical guidelines
Requirements
- 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
