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.