RN, Utilization Management | Utilization Management

Overview

Plays a critical role in evaluating patient medical records to ensure the medical necessity, appropriateness, and efficiency of healthcare services. Collaborates with healthcare providers to support compliance with utilization management guidelines and optimize treatment plans for effective patient care and resource utilization.

Communicates authorization decisions clearly and supports ongoing monitoring of patient progress to facilitate timely and appropriate discharge planning.

Analyzes utilization data to identify trends, opportunities for improvement, and potential areas of risk. Partners with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and adherence to regulatory and compliance standards.

Responsibilities

• Evaluates patient medical records to ensure necessity and appropriateness of healthcare services.
• Coordinates with healthcare providers to maintain compliance with utilization management guidelines.
• Optimizes treatment plans for effective patient care and resource utilization.
• Communicates authorization decisions clearly and supports timely discharge planning.
• Analyzes utilization data to identify trends and improve care coordination.
• Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance.

Qualifications

Registered Nurse (RN) with a current Florida license required.

• Registered Nurse (RN) license with 3+ years experience in utilization review or case management
• Knowledge of healthcare utilization guidelines and compliance
• Experience evaluating medical necessity and treatment plans
• Strong communication skills for authorization decisions
• Ability to analyze utilization data and support care coordination