Utilization Management Nurse

Schedule: Full-Time, Onsite Monday-Friday in Miami, FL.

Description:
The Utilization Management Nurse (RN or LPN) is responsible for coordinating, monitoring, evaluating, and managing utilization review activities and authorization requests for members with complex medical and psychosocial needs. Working collaboratively with Medical Directors, Care Coordination teams, providers, and facilities, this role ensures high-quality, cost-effective healthcare outcomes while maintaining compliance with regulatory standards and medical necessity guidelines.

This position performs concurrent and retrospective reviews for inpatient, observation, and skilled nursing facility services, while supporting safe discharge planning and continuity of care.

What You Will Do:

• Conduct concurrent and retrospective utilization reviews for inpatient, observation, and SNF services.
• Review clinical documentation to determine medical necessity, benefit eligibility, and authorization approvals using established criteria and guidelines.
• Collaborate with Medical Directors, providers, and interdisciplinary teams to support timely and appropriate care decisions.
• Coordinate healthcare services and authorizations in compliance with departmental policies and CMS regulatory timelines.
• Assess member needs and monitor progress toward care goals while communicating updates with the care team.
• Facilitate discharge planning and transitions of care to support safe, effective outcomes.
• Serve as a liaison between members, families, facilities, providers, and internal teams to clarify benefits, policies, and care plans.
• Identify and coordinate community and health plan resources for high-risk and high-cost members.
• Support quality improvement initiatives focused on patient-centered outcomes, resource optimization, and cost containment.
• Escalate complex cases and exception requests to Medical Directors when appropriate.
• Maintain accurate and timely documentation in accordance with organizational and regulatory requirements.

You Will Be Successful If:

• Thrives in a fast-paced, highly regulated healthcare environment.
• Demonstrates strong attention to detail and the ability to manage multiple priorities while meeting strict turnaround times.
• Possesses strong clinical judgment and experience applying medical necessity criteria.
• Communicates effectively with providers, interdisciplinary teams, members, and families.
• Takes a proactive, collaborative, and solutions-driven approach to resolving barriers to care.
• Maintains a strong commitment to improving healthcare outcomes and member experience.

What You Will Bring:

• Active and unrestricted Florida RN or LPN license required.
• Graduate of an accredited school of nursing. Bachelor’s degree in Nursing preferred.
• Minimum of 3-5 years of clinical nursing experience in a healthcare setting.
• At least 2 years of Utilization Management experience within a managed care or payer environment preferred.
• Previous case management experience in a payer or facility setting highly preferred.
• Discharge planning experience strongly preferred.
• Bilingual in English and Spanish required.
• Strong knowledge of utilization review processes, medical necessity criteria, and CMS guidelines.
• Excellent organizational, communication, and critical thinking skills.

About Impresiv Health:

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.

Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.

That’s Impresiv!