Actalent is hiring UM nurses!

Job Description

The Utilization Management Nurse (UMN) plays a crucial role in optimizing the utilization of healthcare services. Working under the general supervision of the Director and/or Manager/Supervisor of Medical Management, and in collaboration with an interdisciplinary team, the UMN reviews service authorization requests to ensure appropriate service utilization. This includes reviewing specialties, medical treatments, elective hospital admissions, rehabilitative services, home care, and out-of-plan referrals. The UMN also assists with complex cases, internal process development, and educates physicians and team members on utilization review issues. Ensuring smooth transitions and patient satisfaction is key to this role.

Responsibilities

• Review prior authorization requests for medical necessity and appropriateness using standardized criteria.
• Coordinate with Medical Directors/Physicians for requests outside of standard criteria.
• Ensure compliance with federal, state, and contractual guidelines.
• Manage caseload by obtaining necessary documentation and addressing discrepancies.
• Serve as a liaison between Medical Directors, physicians, and office staff.
• Perform evaluation and monitoring of resource utilization such as durable medical equipment and hospitalizations.
• Document department work processes and policy guidelines.
• Promote safe and appropriate coordination of care.
• Identify and develop programs, policies, and procedures for continuous quality improvement.
• Maintain confidentiality according to company and department policies.
• Participate in regular departmental training sessions.
• Coordinate enrollee benefits with providers and external organizations.
• Prepare and present reports on department activities.

Essential Skills

• Clinical review
• Utilization review
• Utilization management
• Interqual
• Milliman Commercial Guidelines
• Medicaid
• Medical management
• Medicare
• Managed care
• Patient care
• Medical record management

Additional Skills & Qualifications

• Current unrestricted Florida RN or LPN License
• Minimum of two years of utilization review experience
• Minimum of one year of discharge planning experience in an acute care setting
• Four years of related clinical experience in a healthcare field or equivalent education
• Valid Florida Driver’s License
• Knowledge of case management and utilization review concepts
• Familiarity with Florida Medicaid Program and CMS Guidelines
• Proficiency in word processing software, Microsoft Excel, and electronic medical record software

Work Environment

The role offers a hybrid work schedule post-training, with hours from Monday to Friday, 8am-5pm.