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.