Actalent is hiring a Utilization Management Nurse!

Job Description

The Utilization Management Nurse (UMN) plays a crucial role in reviewing service authorization requests to ensure appropriate service utilization. Working under the general supervision of the Director and/or Manager/Supervisor of Medical Management, and in collaboration with an interdisciplinary team, the UMN manages complex cases and contributes to internal process development. This role involves close interaction with Medical Directors and other Medical Management staff to direct utilization and capture data effectively.

Responsibilities

• Review prior authorization requests for medical necessity and appropriateness, utilizing standardized Review Criteria.
• Coordinate with the Medical Director/Physicians for requests outside standard Review Criteria.
• Maintain compliance with federal, state guidelines, and contractual requirements.
• Obtain necessary documentation, ensuring completion of assigned caseload by addressing discrepancies.
• Serve as a liaison between the Medical Director, physicians, and office staff, resolving prior authorization issues.
• Communicate denial determinations to providers when necessary.
• Evaluate and monitor appropriate utilization of resources such as durable medical equipment, hospitalizations, and home healthcare.
• Provide current and timely documentation reflecting department work processes and policy guidelines.
• Promote safe and appropriate coordination of care and optimal utilization of resources.
• Identify and participate in the development of programs, policies, and procedures for continuous quality improvement.
• Assure adherence to company and department policies regarding confidentiality.
• Participate in regular departmental training.
• Serve as a plan liaison to coordinate enrollee benefits with providers and external organizations.
• Prepare and present reports on department activities as assigned.

Essential Skills

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

Additional Skills & Qualifications

• Current unrestricted Florida RN or LPN License.
• Minimum of one year of utilization review experience and discharge planning in an acute care setting.
• Four years of related clinical experience in a healthcare field or equivalent combination of education and experience.
• Valid Florida Driver’s License.
• Knowledge of case management and utilization review concepts, including InterQual and Milliman Criteria, Florida Medicaid Program, and CMS Guidelines.
• Knowledge of community and post-acute resources and related requirements.
• Proficiency in word processing software, spreadsheet software such as Microsoft Excel, and electronic medical record software.

Work Environment

The role offers a hybrid work schedule with in-office requirements in Sunrise on Tuesdays from 8:30 AM to 5:00 PM, including a 30-minute lunch break. Initial training will take 2-4 weeks, involving shadowing a team member on-site on Tuesdays and remote shadowing via Teams.