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Case Manager RN - Utilization Review

May 1, 2026

Current Employees:If you are a current Staff, Faculty or Temporary employee at the University of Miami, please click <a target="_blank" href="">here</a> to log in to Workday to use the internal application process. To learn how to apply for a faculty or staff position, please review this <a target="_blank" href="">tip sheet</a>.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 TowerCORE JOB FUNCTIONS1. 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 patient’s 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 QUALIFICATIONSEducation:Graduate from an accredited school of nursing, Bachelor’s degree (BSN).Certification and Licensing:Valid State of Florida RN license requiredBasic 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 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. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.Job Status:Full timeEmployee Type:Staff

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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

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When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

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Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

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Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

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