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Medical Case Manager (Nurse or M.D.)

Case Management | Miami, FL | Full Time

Job Description

About Us

We are a service-based company and a licensed Third Party Administrator creating a full-featured software suite for the healthcare industry from scratch. We’re an innovative company creating a unique experience for healthcare professionals. While many industry-wide solutions exist, nothing comes close to our ground-breaking approach.

PayerFusion's innovative services utilize the latest medical claim processing technology coupled with our unique healthcare cost containment methodologies to provide you with the sharpest advantage possible.

We are seeking only top talent and experienced personnel in order to meet and exceed our client's expectations.

About the Position

The Case Manager is the senior clinical member of the case management team.  The CM provides clinical insight and recommendation to clients and customer service staff in order to make determinations of appropriate length of stay and procedures.  The CM also works directly with the hospital case managers and treating physicians on any given episode of care.

Key Responsibilities

  • Adhere to client service level agreements.
  • Review all inpatient cases to provide an estimated length of stay and cost estimate
  • Review and respond to all precertification requests
  • Perform review/audit of medical claims
  • Provide clinical explanations/recommendations to clients and communicate directly with their medical staff
  • Perform other similar and related duties as required.

Job Requirements

  • MD or FMG
  • Excellent analytical and problem resolution skills and ability to maintain high attention to detail are required.
  • Must have excellent verbal and written communication and interpersonal skills to interface with all levels of the organization and clients.
  • Strong decision-making and organizational skills, with the ability to optimize the use of all available resources and deliver on multiple priorities.
  • Exceptional team player with the confidence and integrity to earn client and internal team confidence quickly.
  • Proficient PC skills including intermediate to advanced Microsoft Word, Excel and Outlook skills.
  • Knowledge of ICD and CPT coding and UB guidelines for billing accuracy


  • Experienced in referral for medical plans, insurance companies, hmo's or in primary or specialits medical practice handling referrals, appointments or the gathering of medical information to make case determination
  • Well versed in medical practice guidelines and understanding
  • Knowledge of coding and billing structures for medical providers (hospital, physicians and outpatient centers)
  • Aware of utilization review processes and able to look at best cost with quality


  • We offer excellent benefit package which includes health, dental and vision insurance as well and Paid Time off.