Utilization Review Nurse - Hospital Case Management

Ventura Services Florida; Sunset Corners (FL); On-site; USD 65,000 - 95,000; Full time

Job summary

Ventura Services Florida seeks a qualified Utilization Review Nurse to assess patient records for admission, length of stay, and medical necessity in a hospital setting. The role focuses on prospective, concurrent, and retrospective reviews, coordinating with providers and payers to ensure compliant reimbursement and appropriate care.

Florida RN licensure required; BSN preferred; two years UR/DCP/CM experience.

Qualifications

• Two years UR/DCP/CM experience in a hospital setting.
• RN licensure in Florida is required.
• BSN degree is preferred.

Responsibilities

• Perform admission reviews and provide data to the carrier when requested.
• Maintain system monitoring of admissions and extended stays for timeliness.
• Conduct discharge reviews and advise physicians accordingly.
• Aggregate and analyze data on quality and utilization of patient care.
• Coordinate with providers and payers to obtain proper authorization.
• Prepare reconsideration letters to PRO as needed.
• Support discharge planning and patient/family counseling as needed.

Skills

Attention to detail

Multitasking

Communication skills

Healthcare regulations

Data analysis

Interpersonal skills

Medicare/Medicaid knowledge

Confidentiality

Education

RN Licensure Florida

Associate degree in Nursing

BSN preferred

Job description

Ventura Services Florida seeks a qualified Utilization Review Nurse to assess patient records for admission, length of stay, and medical necessity in a hospital setting. The role focuses on prospective, concurrent, and retrospective reviews, coordinating with providers and payers to ensure compliant reimbursement and appropriate care.

Florida RN licensure required; BSN preferred; two years UR/DCP/CM experience.