RN, Utilization Management

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 necessity and appropriateness of healthcare services.• Coordinates with healthcare providers to maintain compliance with utilization management guidelines.• Optimizes treatment plans for effective patient care and resource utilization.• Communicates authorization decisions clearly and supports timely discharge planning.• Analyzes utilization data to identify trends and improve care coordination.• Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance.
Qualifications

Required Education. Graduate from an accredited Nursing school Required experience: Registered Nurse (RN) license with 3+ years experience in utilization review or case management Necessary Skills • Knowledge of healthcare utilization guidelines and compliance• Experience evaluating medical necessity and treatment plans• Strong communication skills for authorization decisions• Ability to analyze utilization data and support care coordination License Requirement: Registered Nurse (RN) with a current Florida nursing license required.

Share this job

Related Jobs

Utilization Review

Temporary

2 months ago

RN, Utilization Management | Utilization Management| Variable | PRN

UF Health Leesburg, FL

Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: Leesburg, FL 🕒 FTE: PRN (.10 FTE) ⏰ Schedule: Variable 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 Key Responsibilities Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services. Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements. Supports effective treatment planning, patient care coordination, and appropriate resource utilization. Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts. Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency. Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes. Qualifications Education & Licensure Registered Nurse (RN) with a current Florida nursing license required. Experience & Skills Minimum of three (3) years of experience in utilization review, utilization management, or case management required. Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards. Experience evaluating medical necessity, treatment plans, and appropriate levels of care. Strong communication and collaboration skills related to authorization determinations and care coordination. Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.

Utilization Review

Full-time

2 weeks ago

RN, Utilization Management| Day |Full Time

UF Health The Villages, FL

Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: Gainesville, FL 🕒 FTE: Full-Time (1.0FTE) ⏰ Schedule: ( Days-TBD) 8:00 PM – 6:30PM 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 Responsibilities Key Responsibilities Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services. Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements. Supports effective treatment planning, patient care coordination, and appropriate resource utilization. Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts. Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency. Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes. Qualifications Education & Licensure Registered Nurse (RN) with a current Florida nursing license required. Experience & Skills Minimum of three (3) years of experience in utilization review, utilization management, or case management required. Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards. Experience evaluating medical necessity, treatment plans, and appropriate levels of care. Strong communication and collaboration skills related to authorization determinations and care coordination. Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.

RN, Utilization Management | Utilization Management| Day| Full Time

UF Health Tampa, FL

Overview The RN Utilization Managemen t 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 An incumbent in this position will • Evaluates patient medical records to ensure necessity and appropriateness of healthcare services. • Coordinates with healthcare providers to maintain compliance with utilization management guidelines. • Optimizes treatment plans for effective patient care and resource utilization. • Communicates authorization decisions clearly and supports timely discharge planning. • Analyzes utilization data to identify trends and improve care coordination. • Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Required: Registered Nurse (RN) with a current Florida license required. • 3+ years experience in utilization review or case management • Knowledge of healthcare utilization guidelines and compliance • Experience evaluating medical necessity and treatment plans • Strong communication skills for authorization decisions • Ability to analyze utilization data and support care coordination Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.

Utilization Review

Part-time

2 months ago

RN, Utilization Management | Utilization Management| Night | Part Time

UF Health Gainesville, FL

Overview Make an impact by supporting the right care at the right time through utilization management excellence. 💻 Work Style: Onsite 📍 Location: Gainesville, FL 🕒 FTE: Part-Time (.6 FTE) ⏰ Schedule: Wednesday – Thursday - 7:00 PM – 7:00 AM 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 Key Responsibilities Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services. Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements. Supports effective treatment planning, patient care coordination, and appropriate resource utilization. Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts. Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency. Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes. Qualifications Education & Licensure Registered Nurse (RN) with a current Florida nursing license required. Experience & Skills Minimum of three (3) years of experience in utilization review, utilization management, or case management required. Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards. Experience evaluating medical necessity, treatment plans, and appropriate levels of care. Strong communication and collaboration skills related to authorization determinations and care coordination. Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.

Utilization Review

Full-time

2 months ago

RN, Utilization Management Lead | Utilization Management| Day Full Time

UF Health Gainesville, FL

Overview Make an impact by supporting the right care at the right time through utilization management excellence. RN Utilization Lead under the general supervision of the Director, is responsible for department coordination of utilization, other review activities to ensure payment for services is authorized and an active and effective utilization management program is maintained. 💻 Work Style: Onsite 📍 Location: Gainesville, FL 🕒 FTE: Full-time (1.00 FTE) ⏰ Schedule: Thursday-Sunday - 5:30 AM - 4:00 PM Responsibilities Responsible to perform all duties accordance with the utilization review (UR) plan, Federal and State guidelines, as well as TJC standards. Is also responsible for operational logistics in the absence of the Director. Qualifications Minimum Education and Experience Requirements: Re gistered nurse (RN) with current Florida license with a minimum of two (2) years experience performing utilization review in a hospital setting, for a third party payer or other review agency or organization. Knowledge of diagnostic related groups (DRGs), Federal and State guidelines, commercial and other payer groups and coding preferred. Must possess strong written and verbal communication skills. Ability to type and use a computer proficiently required. Licensure/Certification/Registration: Registered Nurse.