Utilization Review

Utilization Management Nurse

The Utilization Management (UM) Nurse performs medical necessity reviews on all payer admissions to determine appropriate admission status and documents all information that relates to insurance reimbursement in appropriate reviews for the Health First Integrated Delivery Network (IDN). The UM Nurse utilizes advanced clinical skills to facilitate the provision of care including the appropriate length of stay, patient status management, and resource utilization for all hospital admissions. The UM Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment and regularly collaborates with the Medical Staff, Physician Advisors, Case Managers, Revenue Cycle and other multi-disciplinary teams.

Evaluates admissions, continued stays, and services with evidence-based criteria (e.g., InterQual, MCG).

Determines whether care is medically necessary, appropriate, and at the right level of care, and identifies over-utilization and under-utilization.

Verifies compliance with Centers For Medicare and Medicaid Services (CMS) Conditions of Participation, Medicare and Medicaid rules, and Commercial payer requirements.

Maintains accurate, defensible documentation, and supports audits and accreditation standards (e.g., Joint Commission, CMS).

Reviews prior authorizations and concurrent approvals, initiating peer-to-peer reviews when criteria are not met, and manages denials, appeals, and retrospective reviews.

Communicates decisions clearly to providers and stakeholders.

Collaborates closely with licensed practitioners and advanced practice providers, case managers and social workers, coding, billing, and finance teams.

Advocates for patients while balancing payer requirements, and promotes efficient, timely progression of care.

Supports appropriate resource utilization without compromising quality.

Identifies opportunities for alternative levels of care (OBS vs IP, SNF, home health, etc.), early discharge planning, while contributing to organizational goals around quality metrics and cost containment.

Education: Associates degree in Nursing (ASN), or Nursing Diploma.

Work Experience: Five (5) years experience in acute care (e.g., critical, intermediate, or emergency department) nursing environments.

Licensure: Registered Nurse (RN) licensure in the State of Florida, or endorsement.

Certification: American Heart Association Basic Life Support (AHA BLS) Healthcare Provider Completion Card prior to start date and maintained.

Strong analytical, data management and computer skills.

Ability to work autonomously and prioritize multiple tasks and role components.

Ability to exercise sound judgment in interactions with physicians, payers, and other customers.

Must be able to work remotely with adequate technology to support and maintain productivity.

Education: BSN or Masters Degree in a healthcare field

Certification: Current Case Manager Certification (CCM or ACM)

Current working knowledge of care transitions, utilization management, case management and managed care reimbursement

Majority of time involves sitting or standing; occasional walking, bending, and stooping.

Long periods of computer time or at workstation.

Light work that may include lifting or moving objects up to 20 pounds with or without assistance.

May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.

Communicating with others to exchange information.

Visual acuity and hand-eye coordination to perform tasks.

Workspace may vary from open to confined.

May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.