RN, Utilization Management | Utilization Management

Overview:

Join an onsite clinical team focused on ensuring the right care at the right time for every patient.

 

 Work Style: Onsite
 Location: The Villages, FL
 FTE: Full-Time (1.0 FTE)
️ Schedule: Monday – Friday (occasional weekends required)

 

Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services in alignment with utilization management guidelines. Collaborates with healthcare providers to support compliance, optimize treatment plans, and promote efficient resource utilization.

 

Communicates authorization decisions clearly and monitors patient progress to support timely discharge planning. Analyzes utilization data to identify trends and opportunities for process improvement.

 

Partners with interdisciplinary teams to enhance care coordination, ensure accurate documentation, and maintain compliance with regulatory and organizational standards.

Responsibilities:

Key Responsibilities

• Evaluates patient medical records to ensure the necessity and appropriateness of healthcare services.
• Coordinates with healthcare providers to ensure compliance with utilization management guidelines.
• Supports the optimization of treatment plans to promote effective patient care and appropriate resource utilization.
• Communicates authorization decisions clearly and supports timely discharge planning.
• Analyzes utilization data to identify trends and opportunities to improve care coordination.
• Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance.

Qualifications:

Education & Experience:

Registered Nurse (RN) with a current Florida license required.

• Three (3) years of critical care nursing experience, or
• Five (5) years of medical-surgical nursing experience, or
• Three (3) years of utilization review, case management, or third-party payer experience.

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Qualifications

• Active Registered Nurse (RN) license with 3+ years of experience in utilization review or case management.
• Strong knowledge of healthcare utilization management guidelines and regulatory compliance.
• Experience evaluating medical necessity and optimizing treatment plans.
• Excellent communication skills with the ability to clearly convey authorization decisions.
• Ability to analyze utilization data and support effective care coordination.
• Strong organizational skills with the ability to manage multiple priorities simultaneously.
• Ability to work independently and collaboratively with multidisciplinary teams.
• Strong attention to detail and innovative problem-solving skills.
• Flexibility to adjust work hours and days based on departmental needs.

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Motor Vehicle Operator Designation:
Employees in this position will not operate vehicles for an assigned business purpose.

Note: Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time of submission.

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Licensure/Certification/Registration:

• Registered Nurse (RN) with a current Florida license required.