Current Employees: If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click here (https://www.myworkday.com/umiami/d/task/1422$7248.htmld) to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position using the Career worklet, please review this tip sheet (https://my.it.miami.edu/wda/erpsec/tipsheets/ER\_eRecruiting\_ApplyforaJob.pdf) . CORE JOB FUNCTIONS 1. Performs medical tests in patients to diagnose their health condition.2. Interprets laboratory test results of patients.3. Recommends treatment plan for patients based on diagnosis.4. Counsels individuals and patients on positive health practices.5. Provides the latest cost-effective nursing practices.6. Collaborates with other team of experts to outline best treatment for patients.7. Performs holistic evaluation of specialty population, making use of enhanced proven techniques and procedures to achieve better results.8. Implements the improvement of patient care, and healthcare policies and resources.9. Mentors other healthcare professionals by functioning as a preceptor or coordinating preceptors for visiting professionals, students, new graduates, and orienteers.10. Maintains professional knowledge by affiliating with professional and technical organizations, and participating in applicable continuing education programs, conferences, seminars, and workshops.11. Adheres to University and unit-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. Department Specific Functions: General Functions: + Able to perform duties of Utilization Review RN including obtaining authorization, initiating appeal for treatment, submitting required literature, reviewing treatment guidelines etc. + Functions as a patient advocate while collaborating with the multidisciplinary team. + Serves as a resource to external contacts and staff in securing authorization for treatment. + Meets the expectations of the patient, families and clinical team by listening to them demonstrating sensitivity and awareness of others. + Serves as a role model and mentor demonstrating appropriate knowledge and expertise regarding Utilization review. + Participate in workload analysis to ensure equal distribution of workload to the team. + Ensures compliance with all institutional policies and procedures including mandatory services, employee health procedures, Federal, State, regulatory and accrediting agencies standards and regulations. + Other duties as assigned. Denial Prevention: + Conducts quality audits of work performed by clinical staff and present findings and recommendation for areas of improvement to management. + Collaborates with management, pharmacy, central business office and finance to identify and address areas for opportunity. + Analyzes root cause of denials for process improvement implementation by managing work queue with Central Business Office. + Presents recommendations to Utilization Review Committee. + Maintains denial data set as required. + Partner with Central Business Office to participate in appeal process as needed, provide support and process recommendations to support appeal processes. Payer Trends: + Reviews payer websites and available information to look for policy language/policy tracking to educate the Utilization review staff on any payer behavior changes. + Partners with payer resources and staff to receive notification impacting payer policies and processes and share with physicians and staff. + Maintain and deploy key documents and policies by payer to facilitate access for Utilization Review staff. + Maintain Utilization Review payer guide. + Works closely with managed contracts to anticipate and plan for changes that will impact infusion services. Minimum Qualifications: Education: Bachelor’s Degree Certification and Licensing: Registered Nurse Licensing (RN) Experience: Minimum 3 years of relevant work experience Knowledge, Skills and Attitudes: + Ability to maintain effective interpersonal relationships + Ability to communicate effectively in both oral and written form + Skill in collecting, organizing and analyzing data + Proficiency in computer software (i.e. Microsoft Office) + Ability to communicate clearly, concisely, verbal and in writing. + Critical thinking and problem-solving skills regarding clinical review, criteria and response to denials + Ability to research denials from clinical areas, such as the comprehensive treatment units, and articulate a clear, concise response to the billing department + Subject matter expert and knowledge of payer guidelines, CMS LCD/NCD guidelines and nationally recognized treatment guidelines + Ability to multi-task and work independently + Develop template letters for commonly denied and appealed medications to facilitate successful overturn of denied request or treatment. Education and Training: + Maintain knowledge of best practices in Utilization Review, share with staff internal and external to Utilization Review. + Work with Utilization Review Manager to develop and deploy Utilization Review staff onboarding to ensure training meets requirements of role. + Responsible for conducting training programs and ongoing competency deployment for Utilization review department. + Responsible for development and deployment of training programs for providers and staff external to Utilization Review department. + Maintain records of training activities and employee progress. + Develop and maintain literature library to facilitate authorization requests, appeals etc. 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 Florida's 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. We're the challenge you've been looking for. The University of Miami is an Equal Opportunity Employer - Females/Minorities/Protected Veterans/Individuals with Disabilities are encouraged to apply. Applicants and employees are protected from discrimination based on certain categories protected by Federal law. Click here (https://www.hr.miami.edu/careers/eo-ada/index.html) for additional information. Job Status: Full time Employee Type: Staff Pay Grade: H14