Remote Utilization Review RN – PACE & Post-Acute Care

Miami-Jewish-Health; Miami (FL); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical/dental/vision coverage

403(b) retirement plan

Free on-campus parking

Onsite fitness center

Job summary

Florida PACE Centers, Inc. is seeking a Utilization RN to conduct prospective, concurrent, and retrospective reviews ensuring medical necessity and appropriate level of care across the continuum.

The role collaborates with hospital UR/Case Management, IDT, and community providers to support timely care transitions. The ideal candidate has 2–4 years in healthcare/utilization management, an active Florida RN license, and familiarity with InterQual/MCG criteria and payer policies.

Qualifications

• Associate's or Bachelor's degree in Nursing required.
• 2–4 years in healthcare administration/utilization management; 2+ years in acute/post-acute settings.
• Current RN license in Florida; CCM/CPUR/CPHQ preferred.
• Knowledge of InterQual/MCG criteria, CMS/Medicaid requirements.

Responsibilities

• Perform admission, continued stay, and discharge reviews across inpatient, observation, and post-acute services.
• Apply evidence-based criteria and payer policies to determine medical necessity and level of care.
• Communicate authorization decisions within required turnaround times; escalate as needed.
• Coordinate with hospital UR/CM, IDT, and providers to plan timely discharge.

Skills

Clinical knowledge and judgement

CMS/Medicaid policies

InterQual/MCG criteria

RN license (FL)

EMR systems

MS Office (Outlook, Excel)

Travel to hospitals

Education

Associate's or Bachelor's degree in Nursing

Tools

EMR platforms

MS Office

Job description

Florida PACE Centers, Inc. is seeking a Utilization RN to conduct prospective, concurrent, and retrospective reviews ensuring medical necessity and appropriate level of care across the continuum.

The role collaborates with hospital UR/Case Management, IDT, and community providers to support timely care transitions. The ideal candidate has 2–4 years in healthcare/utilization management, an active Florida RN license, and familiarity with InterQual/MCG criteria and payer policies.