Utilization Management Nurse: Care Coordination (Hybrid)

South Florida Community Care Network Llc; Florida; Hybrid; USD 45,000 - 50,000; Full time

Job summary

South Florida Community Care Network, LLC in Sunrise, FL is seeking an Utilization Management Nurse to review service authorizations and support optimal care. The role collaborates with the interdisciplinary team to ensure appropriate utilization, educate physicians and staff, and oversee continuity of care and patient safety.

The UMN will work under supervision in Medical Management, handle complex cases, and contribute to process improvement while maintaining confidentiality and compliance

Qualifications

• Current unrestricted Florida RN or LPN license.
• Minimum of two years utilization review experience and one year discharge planning in acute care desirable.
• Four years related clinical experience; or equivalent education/experience.
• Knowledge of InterQual, Milliman criteria, Florida Medicaid and CMS guidelines.
• Knowledgeable about community and post-acute resources.
• Proficient in word processing, spreadsheets and EMR software.

Responsibilities

• Reviews prior authorization requests for medical necessity and appropriateness using standard criteria.
• Coordinates with Medical Director for requests outside standard criteria.
• Ensures compliance with federal/state guidelines and contractual requirements.
• Obtains documentation and follows up until a determination is made.
• Acts as liaison between Medical Director, physicians, and staff on prior authorizations.
• Monitors utilization of resources including durable medical equipment and home health care.
• Maintains timely department documentation and policy guidance.

Skills

Utilization review knowledge

Discharge planning

Critical thinking

Communication skills

Clinical judgment

Time management

Education

Current unrestricted Florida RN or LPN License

Two years utilization review experience

Four years clinical experience in healthcare

Tools

Microsoft Excel

EMR software

Job description

South Florida Community Care Network, LLC in Sunrise, FL is seeking an Utilization Management Nurse to review service authorizations and support optimal care. The role collaborates with the interdisciplinary team to ensure appropriate utilization, educate physicians and staff, and oversee continuity of care and patient safety.

The UMN will work under supervision in Medical Management, handle complex cases, and contribute to process improvement while maintaining confidentiality and compliance