Utilization Management Nurse: Care Coordination

Community Care Plan; Florida; Hybrid; USD 45,000 - 50,000; Full time

Job summary

South Florida Community Care Network, LLC invites applications for an Utilization Management Nurse (UMN) in Sunrise, FL. The role reviews service-authorization requests, collaborates with the Medical Management team, and educates providers on utilization review.

Ideal candidates hold a Florida RN or LPN license with UR and discharge planning experience, and will contribute to quality, safety, and efficient transitions of care within a hybrid work model.

Qualifications

• Current unrestricted Florida RN or LPN license.
• Two years utilization review and one year discharge planning in acute care desirable.
• Four years clinical experience in healthcare or equivalent.
• Knowledge of case management and utilization review concepts.
• Familiar with InterQual, Milliman Criteria, Florida Medicaid and CMS guidelines.
• Knowledge of community and post-acute resources.
• Proficient with Microsoft Office and EMR software.

Responsibilities

• Review prior authorization requests for medical necessity using standard criteria.
• Coordinate with Medical Director for requests outside standard criteria.
• Ensure compliance with federal/state guidelines and timely processing.
• Gather documents and follow up until determinations are made.
• Act as liaison between Medical Director, physicians and staff on prior authorizations.
• Prepare reports on department activities.

Skills

Case management concepts

Utilization review concepts

InterQual

Milliman criteria

CMS guidelines

Post-acute resources

Microsoft Excel

EMR software

Education

RN or LPN license (FL)

Job description

South Florida Community Care Network, LLC invites applications for an Utilization Management Nurse (UMN) in Sunrise, FL. The role reviews service-authorization requests, collaborates with the Medical Management team, and educates providers on utilization review.

Ideal candidates hold a Florida RN or LPN license with UR and discharge planning experience, and will contribute to quality, safety, and efficient transitions of care within a hybrid work model.