RN, Utilization Management | Utilization Management | Onsite

UF Health Central Florida; The Villages (FL); On-site; USD 70,000 - 90,000; Full time

Job summary

A healthcare provider in Florida is seeking a Registered Nurse to play a critical role in evaluating patient medical records for healthcare necessity. The ideal candidate will coordinate with healthcare providers, support discharge planning, and analyze utilization data for improved care coordination. Candidates must have an active RN license and 3+ years of relevant experience, showcasing strong communication and organizational skills. This position does not involve operating vehicles for business purposes.

Qualifications

• Three (3) years of critical care nursing, or five (5) years of medical-surgical nursing experience.
• Strong knowledge of healthcare utilization management guidelines.

Responsibilities

• Evaluate patient medical records for healthcare service necessity.
• Coordinate compliance with utilization management guidelines.
• Support optimization of treatment plans.
• Communicate authorization decisions effectively.
• Analyze utilization data for trends.
• Collaborate with interdisciplinary teams.

Skills

Critical care nursing experience

Medical-surgical nursing experience

Utilization review experience

Excellent communication skills

Organizational skills

Problem-solving skills

Education

Active Registered Nurse (RN) license

3+ years of experience in nursing

Job description

Overview

Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance.

Responsibilities

• Evaluates patient medical records to ensure the necessity and appropriateness of healthcare services.
• Coordinates with healthcare providers to ensure compliance with utilization management guidelines.
• Supports the optimization of treatment plans to promote effective patient care and appropriate resource utilization.
• Communicates authorization decisions clearly and supports timely discharge planning.
• Analyzes utilization data to identify trends and opportunities to improve care coordination.
• Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance.

Qualifications

Education & Experience:

• Three (3) years of critical care nursing experience, or
• Five (5) years of medical-surgical nursing experience, or
• Three (3) years of utilization review, case management, or third-party payer experience.

• Active Registered Nurse (RN) license with 3+ years of experience in utilization review or case management.
• Strong knowledge of healthcare utilization management guidelines and regulatory compliance.
• Experience evaluating medical necessity and optimizing treatment plans.
• Excellent communication skills with the ability to clearly convey authorization decisions.
• Ability to analyze utilization data and support effective care coordination.
• Strong organizational skills with the ability to manage multiple priorities simultaneously.
• Ability to work independently and collaboratively with multidisciplinary teams.
• Strong attention to detail and innovative problem-solving skills.
• Flexibility to adjust work hours and days based on departmental needs.

Motor Vehicle Operator Designation

Employees in this position will not operate vehicles for an assigned business purpose.

Note: Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time of submission.

Licensure/Certification/Registration

• Registered Nurse (RN) with a current Florida license required.