RN, Utilization Management | Utilization Management | Onsite

UF Health; Town of Florida (NY); On-site; USD 70,000 - 90,000; Full time

Job summary

A healthcare organization is seeking an experienced Registered Nurse (RN) in Florida. The role involves evaluating patient medical records for necessary healthcare services and ensuring compliance with management guidelines. Candidates should have strong experience in utilization review or case management and excellent communication skills. This position requires the ability to analyze data and coordinate care effectively within a multidisciplinary team.

Qualifications

• Active RN license with strong experience in utilization management required.
• Proven track record in case management or critical care nursing.
• Must possess excellent communication skills for authorization decisions.

Responsibilities

• Evaluate patient medical records for healthcare service necessity.
• Coordinate with providers for compliance with management guidelines.
• Analyze utilization data to enhance care coordination.

Skills

Utilization review

Case management

Critical thinking

Communication

Analytical skills

Attention to detail

Organizational skills

Education

Active Registered Nurse (RN) license

3+ years of experience in utilization review or case management

3 years of critical care nursing experience or 5 years of medical-surgical 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.

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.

Qualifications

• 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.