About this opportunity
American Oncology Management Company lists this Clinical Utilization Management Coordinator - RN/LPN opportunity in macon, Georgia. Review the employer’s description below for duties, qualifications and application requirements.
Job description
Location:
Central Georgia Cancer CareHiring Range:
$30.34 - $43.97 Position Summary:
The Clinical Utilization Management Coordinator role is to ensure that health care services are administered with quality, drug cost efficiency, and compliant with payer policy. By continuously reviewing and auditing patient treatment files, the utilization nurse will ensure that patients won't receive treatment/procedures without pre-authorization from payer obtained. Communicating to provider payer position specific to medical necessity
Key Performance Areas
KPA 1 - Utilization Management & Authorization Review
Conduct concurrent review of patient clinical information to ensure active pre-authorization is maintained for scheduled treatments and procedures.
Review precertification and authorization requests for medical necessity and verify that required approvals are in place prior to treatment delivery.
Monitor new treatment plans, treatment changes, and other clinical activities that may impact existing authorizations or require additional payer approval.
Apply clinical knowledge, critical thinking, and independent judgment when reviewing authorization requirements and resolving payer-related issues.
KPA 2 - Payer Coordination & Requirements
Communicate with payer plans regarding authorization requirements, coverage determinations, and treatment-related approvals.
Identify and communicate payer-imposed requirements that may impact treatment delivery, including formulary restrictions, pharmacy substitutions, and other coverage limitations.
Partner with providers to address payer exceptions and facilitate necessary treatment modifications when required by the patient's health plan.
KPA 3 - Provider & Clinical Team Communication
Provide timely updates to physicians, clinical teams, and other healthcare providers regarding authorization status, outstanding requirements, and payer determinations.
Coordinate with clinical and non-clinical staff supporting treatments that require pre-authorization.
Escalate authorization barriers or payer-related concerns that may delay or impact treatment.
KPA 4 - Patient Care Support
Advocate for timely, high-quality patient care while ensuring treatment plans remain aligned with payer requirements and authorization guidelines.
Support continuity of care by proactively identifying authorization issues that could affect treatment scheduling or delivery.
KPA 5 - Documentation & Compliance
Maintain accurate, complete, and timely documentation of all pre-authorization, precertification, payer communication, and related utilization management activities.
Ensure authorization-related records are maintained in accordance with organizational procedures and applicable payer requirements.
Manage multiple priorities in a fast-paced environment with minimal supervision.
Maintain a high level of organization, accuracy, and follow-through when managing authorization activities.
Demonstrate effective interpersonal and communication skills when working with providers, clinical staff, payers, and other stakeholders.
Position Qualifications/Requirements
Education
Graduate of an accredited nursing program with current LPN or RN licensure.
Minimum Relevant Experience
Two years LPN or RN experience; physicians practice; oncology preferred.
Two years experience in utilization management and obtaining insurance authorizations in a medical setting.
Relevant clerical or case management work in a medical office setting.
Must have excellent interpersonal and communication skills, be very detail-oriented and a self-starter.
Certifications/Licenses
State Licensure as a Licensed Practice Nurse (LPN) or Registered Nurse (RN)
Utilization Management or Case Management certification preferred
Skills
Communication
Organization
Collaboration
Documentation
Analysis
Advocacy
Travel: 0-25%
Expectations for All Employees
This position description reflects the general duties and responsibilities necessary to perform the principal functions of the job, as identified, and shall not be considered an exhaustive list of job responsibilities which may be inherent in the job. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. The responsibilities listed may be subject to change at any time and individuals may be asked to perform duties outside of their regular responsibilities to support the ongoing business operation needs.
Americans with Disabilities Act (ADA) Compliance
The essential functions described herein are intended to define the fundamental duties of the position and serve as the minimum requirements for performance. They do not represent an exhaustive list of all job duties that may be required. AON complies with the Americans with Disabilities Act (ADA) and applicable state and local laws. The Company will engage in an interactive process to evaluate and, where appropriate, provide reasonable accommodations to qualified individuals with disabilities, provided such accommodations do not impose an undue hardship on the business.
Physical Requirements
Sitting for extended periods
Occasional walking and standing
Ability to use computer and phone
Cognitive Requirements
Interpersonal communication
Data entry accuracy
Understanding of billing and insurance procedures
Environmental Requirements
Office environment within patient care areas
Potential exposure to airborne illnesses
Accommodation Notes
Ergonomic seating
Flexible schedules
Accessible workstations
Screen reader software
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Who can apply
Review the original listing for work authorization, qualifications and employer requirements.