Utilization Review Nurse — Clinical Insight & Impact

TurningPoint Healthcare Solutions; Florida; On-site; USD 65,000 - 85,000; Full time

Job summary

TurningPoint Healthcare Solutions is seeking a Utilization Review Nurse to perform first-level clinical reviews using established medical criteria for authorization decisions. The role requires independent work, attention to detail, and the ability to meet deadlines in a fast-paced healthcare environment.

Ideal candidates are licensed RNs or LPNs with strong nursing knowledge, excellent communication, and proficient computer skills to navigate multiple programs.

Qualifications

• Licensed RN or LPN required.
• Strong nursing theory knowledge.
• Excellent customer service and phone etiquette.
• Proficient computer skills and ability to navigate various programs.
• Prior utilization management experience preferred but not required.
• Knowledge of musculoskeletal, cardiac, pain management or wound care is a plus.
• Ability to multi-task and meet deadlines in a fast-paced environment.”

Responsibilities

• Perform initial clinical reviews and provide documented recommendations based on appropriate clinical guidelines.
• Review initial evaluation and clinical documentation against clinical standards, state regulations and treatment guidelines.
• Assist clinical staff in quality improvement projects with feedback to clients and providers within scope of practice.
• Resolve patient care issues by working with community providers and staff to finalize determinations.
• Respond to queries from physicians and practice staff; sort and distribute messages and documents.
• Improve quality by evaluating procedures and recommending changes.
• Adhere to accreditation standards, professional standards, company policies and regulatory requirements.

Skills

Nursing knowledge

Customer service

Communication

Computer skills

Multitasking

Teamwork

Education

Registered Nurse (RN)

Licensed Practical Nurse (LPN)

Job description

TurningPoint Healthcare Solutions is seeking a Utilization Review Nurse to perform first-level clinical reviews using established medical criteria for authorization decisions. The role requires independent work, attention to detail, and the ability to meet deadlines in a fast-paced healthcare environment.

Ideal candidates are licensed RNs or LPNs with strong nursing knowledge, excellent communication, and proficient computer skills to navigate multiple programs.