Remote Utilization Management Nurse — Care Optimization

Health First; Melbourne (FL); On-site; USD 85,000 - 105,000; Full time

Job summary

Health First is seeking an Utilization Management (UM) Nurse to perform medical necessity reviews, determine admission status, and document information for insurance reimbursement in the IDN. The role uses advanced clinical skills to optimize length of stay, patient status, and resource use across hospital admissions.

The UM Nurse will collaborate with medical staff, physician advisors, case managers, revenue cycle and multidisciplinary teams in a fast-paced, regulatory environment.

Qualifications

• ASN or Nursing Diploma required.
• RN licensure in Florida required.
• AHA BLS Healthcare Provider card required before start date.
• 5 years of acute care nursing experience.
• Strong analytical, data management and computer skills.
• Ability to work remotely with adequate technology.
• Ability to prioritize multiple tasks.

Responsibilities

• Evaluates admissions and services using evidence-based criteria (InterQual, MCG).
• Determines medical necessity and appropriate level of care.
• Verifies CMS/Medicare/Medicaid and commercial payer requirements.
• Maintains accurate, defensible documentation for audits and accreditation.
• Reviews prior authorizations and concurrent approvals; manages denials and appeals.
• Communicates decisions clearly to providers and stakeholders.
• Collaborates with licensed practitioners, case managers and finance teams.
• Identifies opportunities for alternative levels of care and supports timely discharge planning.

Skills

Analytical skills

Data management

Computer skills

Autonomy

Judgment

Education

ASN or Nursing Diploma

BSN or Master’s in healthcare

CCM or ACM certification

Job description

Health First is seeking an Utilization Management (UM) Nurse to perform medical necessity reviews, determine admission status, and document information for insurance reimbursement in the IDN. The role uses advanced clinical skills to optimize length of stay, patient status, and resource use across hospital admissions.

The UM Nurse will collaborate with medical staff, physician advisors, case managers, revenue cycle and multidisciplinary teams in a fast-paced, regulatory environment.