Utilization Management Nurse

divh2Utilization Management Nurse/h2pSchedule: Full-Time, Onsite Monday-Friday in Miami, FL./ph3Job Description/h3pThe 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./ph3Responsibilities/h3ulliConduct concurrent and retrospective utilization reviews for inpatient, observation, and SNF services./liliReview clinical documentation to determine medical necessity, benefit eligibility, and authorization approvals using established criteria and guidelines./liliCollaborate with Medical Directors, providers, and interdisciplinary teams to support timely and appropriate care decisions./liliCoordinate healthcare services and authorizations in compliance with departmental policies and CMS regulatory timelines./liliAssess member needs and monitor progress toward care goals while communicating updates with the care team./liliFacilitate discharge planning and transitions of care to support safe, effective outcomes./liliServe as a liaison between members, families, facilities, providers, and internal teams to clarify benefits, policies, and care plans./liliIdentify and coordinate community and health plan resources for high-risk and high-cost members./liliSupport quality improvement initiatives focused on patient-centered outcomes, resource optimization, and cost containment./liliEscalate complex cases and exception requests to Medical Directors when appropriate./liliMaintain accurate and timely documentation in accordance with organizational and regulatory requirements./li/ulh3Qualifications/h3ulliThrives in a fast-paced, highly regulated healthcare environment./liliDemonstrates strong attention to detail and the ability to manage multiple priorities while meeting strict turnaround times./liliPossesses strong clinical judgment and experience applying medical necessity criteria./liliCommunicates effectively with providers, interdisciplinary teams, members, and families./liliTakes a proactive, collaborative, and solutions-driven approach to resolving barriers to care./liliMaintains a strong commitment to improving healthcare outcomes and member experience./li/ululliActive and unrestricted Florida RN or LPN license required./liliGraduate of an accredited school of nursing. Bachelors degree in Nursing preferred./liliMinimum of 3-5 years of clinical nursing experience in a healthcare setting./liliAt least 2 years of Utilization Management experience within a managed care or payer environment preferred./liliPrevious case management experience in a payer or facility setting highly preferred./liliDischarge planning experience strongly preferred./liliBilingual in English and Spanish required./liliStrong knowledge of utilization review processes, medical necessity criteria, and CMS guidelines./liliExcellent organizational, communication, and critical thinking skills./li/ul/div