Actalent is hiring a Utilization Management Nurse!

Job Description

The Utilization Management Nurse (UMN) collaborates closely with the interdisciplinary team to perform reviews of service authorization requests, ensuring the utilization of appropriate services. The UMN assists in complex cases, develops internal processes, and educates physicians on utilization review issues. The role involves managing continuity of care, ensuring smooth transitions, patient satisfaction, safety, and appropriate length of stay.

Responsibilities

• Review prior authorization requests for medical necessity and appropriateness using standardized Review Criteria.
• Coordinate with the Medical Director/Physicians for requests outside standard Review Criteria.
• Maintain compliance with federal and state guidelines as well as contractual requirements.
• Obtain necessary documentation and ensure completion of assigned caseload.
• Serve as a liaison between the Medical Director, physicians, and office staff to resolve authorization issues.
• Communicate denial determinations to providers when indicated.
• Perform evaluation and concurrent monitoring of appropriate utilization of resources.
• Provide 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 developing programs, policies, and procedures for continuous quality improvement.
• Ensure 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/or 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
• Case management
• Concurrent review
• Discharge planning
• Medical
• Acute care

Additional Skills & Qualifications

• Current unrestricted Florida RN or LPN License.
• Minimum of one year of utilization review experience.
• Minimum of one year of experience in discharge planning in an acute care setting highly desirable.
• 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.
• Knowledge of Florida Medicaid Program and CMS Guidelines.
• Proficient in word processing software, spreadsheet software such as Microsoft Excel, and electronic medical record software.

Work Environment

This position offers a hybrid work schedule, with in-office work in Sunrise on Tuesdays from 8:30 AM to 5:00 PM, including a 30-minute lunch. Training will take between 2-4 weeks, with opportunities to shadow team members onsite and through Teams.