26 Results for

Utilization Management Nurse Jobs in Miami, FL

Jobs

Hollywood, FL7 days ago

Assists the Case Management staff in resolving patient care issues for referred cases, provides physician education, and assists the hospital and medical staff in developing and promoting resource management goals and objectives. This includes, but not limited to: Makes decisions on referred individual patient cases regarding pre-admission authorization, medical necessity and services/setting, appropriateness of admission, and continuation stay.

Hollywood, FL7 days ago

Must be able to provide education and resources relevant to the effective progression of care, utilization of services, appropriate level of care, and safe patient transition to the patient/family and health care team. Complexity of Work: This role requires critical thinking skills, effective communication, decisive judgment, and the ability to build and foster positive relationships.

Hollywood, FL7 days ago

Must be able to provides education and resources relevant to the effective progression of care, utilization of services, appropriate level of care, and safe patient transition to the patient/family and healthcare team. Complexity of Work: This role requires critical thinking skills, effective communication, decisive judgment, and the ability to build and foster positive relationships.

Cooper City, FL30+ days ago

Remote

The Clinical Appeals Nurse supports HBiz’s revenue cycle operations by reviewing denied claims for clinical accuracy and medical necessity, developing evidence-based appeal strategies, and drafting payer-ready appeal documentation. Collaborate with coding, CDI, denial recovery, and operations teams to strengthen appeal strategy .

Miami, FL9 days ago

Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. Collaborating closely with the Rehab Program Director, Facility Case Management Director, and interdisciplinary team to ensure seamless, patient-centered care .

Miami, FL8 days ago

Collaborating closely with the Rehab Program Director, Facility Case Management Director, and interdisciplinary team to ensure seamless, patient-centered care . Three years’ clinical, hospital nursing experience required with preference given to those with 2 years of case management experience or 2 years of critical care experience .

Pembroke Pines, FL16 days ago

The Medical Case Managers responsibilities include but are not limited to: assessment of strengths and weaknesses, implementation of a treatment plan, coordination and availability of resources, familiarity with the insured policy and its’ limitations and the communication and documentation with the appropriate entities that require information as per the stated policies and procedures while adhering to HIPAA and/or GDPR compliance. The Medical Case Manager is a Licensed Practical Nurse or a Registered Nurse who is accountable and capable of securing and reviewing clinical data in order to approve requests for admissions, procedures and services that meet clinical review criteria.

New!

Miami, FL3 days ago

Remote

$90,000–$105,000

A minimum of 4 years' RN experience in a related role; clinical experience in oncology, infusions or critical care, including care navigation, treatment support, and/or complex case management is required. As the Clinical Nurse Navigator of a growing program, your role encompasses advanced clinical oversight, pathway alignment, interdisciplinary coordination, and escalation authority to providers.

Hialeah, FL30+ days ago

Performs Case Management activities to assure medical necessity of admissions and appropriateness of continued stay utilizing the Interqual Criteria guidelines. Maintains confidential communication with physicians and multi-disciplinary personnel to meet individual needs or the patients served.

Hollywood, FL30+ days ago

$30.75–$33 Per Hour

Infinite Medical P.C. is a nationwide network of advanced practice providers and specialty clinicians committed to delivering high-quality, proactive care directly to residents in skilled nursing and long-term care facilities. Our partnership with MedElite Healthcare Management Group empowers us to focus on what matters most: providing compassionate, personalized care that meets the unique needs of each resident.

New!

Fort Lauderdale, FL5 days ago

Remote

Contractor

Transitions: Care transition support, follow-up coordination, and avoidable readmission prevention for discharged inpatient, observation and emergency department patients Quality: Medicare Advantage Stars, HEDIS and quality performance across value-based population Population Health: Deliver culturally appropriate chronic disease education to activate patients are chronic disease self-management, particularly in Diabetes and Hypertension Duties and Responsibilities: Analyze clinical data and trends from platforms such as Athena EMR and DataHub to identify gaps in care related to HEDIS measures and Transitions of Care and post-hospitalization needs, prioritizing high-impact opportunities. The Clinical Care RN plays a critical role in advancing clinical quality, supporting patients across transitions of care, improving patient outcomes, and contributing to Medicare Advantage Stars ratings by proactively identifying care opportunities, engaging patients and providers, and driving evidence-based interventions.

New!

Plantation, FL3 days ago

Three years’ clinical acute care (i.e. Med-Surg, Tele, PACU, ICU, CVICU etc) hospital nursing experience required with preference given to those with 2 years of case management experience or 2 years of critical care experience. The Case Manager (CM) ensures high-quality, patient-centered care by managing Rehabilitative care to ensure optimum outcomes.

Miami, Florida30+ days ago

Job Summary: Job Title: Specialized Dialysis RN Location: Miami VA Healthcare System (including 7 Community-Based Outpatient Clinics) Period of Performance: 08/12/2025 – 08/11/2030 Shift Schedule: PRN; ten (10) hour shift 6:30am-5pm Position Description: The Dialysis Registered Nurse (RN) provides specialized care to patients with end-stage renal disease (ESRD), acute kidney injury (AKI), and late-stage chronic kidney disease (CKD) in both inpatient and outpatient settings. Minimum Qualifications: Requirements: • BLS and ACLS certifications accredited by the American Heart Association (AHA) • Unrestricted license to practice nursing in one of the States, Territories, or Commonwealths of the United States or the District of Columbia • Experience: Minimum of three (3) years of current nursing experience providing hemodialysis and peritoneal dialysis • Education: ASN accepted; BSN preferred Education must have been completed at a school accredited by the ACEN or CCNE.

Miami, Florida30+ days ago

Dialysis RN Skills: The RN Dialysis nurse include but are not limited to: Professional nurse with specialized knowledge and demonstrates advanced beginner skills when providing and directing care for patients with end-stage renal disease (ESRD), acute kidney injury (AKI), and late-stage chronic kidney disease (CKD). The Dialysis Registered Nurse (RN) provides specialized care to patients with end-stage renal disease (ESRD), acute kidney injury (AKI), and late-stage chronic kidney disease (CKD) in both inpatient and outpatient settings.

Miami, FL30+ days ago

Educate oncologists’ support team: nurses, pharmacists, etc. that engage with patients in community oncology offices and infusion centers on the disease state of gastric, esophageal, and GEJ cancer. By joining one of our field medical teams, you will partner with some of the most talented clinicians in the industry and be reminded why you chose a career in healthcare.

Cooper City, FL30+ days ago

The ideal candidate brings a strong background in clinical review, medical necessity denials, payer appeal processes, and team leadership—ideally across both U.S. and offshore teams (e.g., Philippines). We are seeking an experienced and highly organized Manager of Clinical Appeals to lead our clinical appeals operations across commercial and government payers.

New!

Miami, FL4 days ago

Full-time

Assist in the development and execution of strategic and clinical outcomes achievement plans for the account; Advise client on the roadmap for achieving outcomes, our interactive patient care tools and their effectiveness regarding outcomes as well as the overall utilization of the Get Well system. Responsibilities: Develop, manage and maintain excellent relationships with all nursing staff, hospital administrators and other key client contacts; Serve as one of the primary points of contact in our account model for the client, providing superior customer service to patients, nurses, administrators, other staff members.

Plantation, FL12 days ago

Schedules assessments for all Medicare residents to meet PPS guidelines, notifies appropriate staff assessment dates and assures that required time frames are met without exception. Completes and faxes to the corporate office the Medicare Verification of Funding form in a timely manner (By Day 5 upon admission and upon RUGS III level change during stay).

New!

Aventura, FL3 days ago

The Clinical Rehabilitation Specialist utilizes appropriate patient information sources as well as direct communications with other members of the patient’s care team to identify those patients who may need acute inpatient rehabilitation services prior to returning home. The Clinical Rehabilitation Specialist will review these patients daily until they have strong clinical evidence to request a physician order for a formal pre-admission assessment for acute inpatient rehab through their assigned case manager.

New!

Aventura, FL3 days ago

Miami, FL30+ days ago

Full-time

Responsible for the handling of assigned grievances referred by contracted health plan partners, writing acknowledgements, obtaining pertinent records as needed, researching cases, resolving issues, and ensuring time frames are met for acknowledgement and resolution. Works closely with internal departments to resolve and research health plan member grievances and to obtain additional information to provide to the health plan to adequately resolve and respond to the grievance.

New!

Plantation, FL2 days ago

Successful performance of essential functions can best be achieved through consistent application of current knowledge, use of good judgment, commonsense, ability to establish and carry out priorities, effective use of interpersonal skills and ongoing communication with residents, staff, families, interdisciplinary team members, and other coworkers. This job cannot be performed without exposure to the stresses associated with an intimate, 24-hour resident care environment that delivers care and services primarily to disabled and cognitively impaired residents of varying ages, predominantly the pediatric population.

Doral, FL30+ days ago

The AVP of Clinical Performance oversees the strategy, operations, and performance of Delegated Utilization Management (UM) and Care Management (CM) programs that ensure healthcare services are medically necessary, cost-effective, and aligned with payer and regulatory requirements. This role will be directly responsible for the management of clinical capabilities related to delegated utilization management and delegated care management across multiple health plan clients in the California Medi-Cal, Medicaid delegated services markets.

Miami, FL30+ days ago

Full-time

Founded in 2003 by a team of Taiwanese-American executives and renowned scientists from U.S. biotechnology and pharmaceutical companies, today we are listed on the Taiwan Stock Exchange (TWSE: 6446) and are expanding our global presence with operations in the U.S., Japan, Singapore, South Korea, and China, along with a world-class biologics production facility in Taichung. Entrepreneurial ExpertiseBecoming a true subject matter expert on all key topics that impact the success of the business – disease state knowledge, clinical acumen, product expertise, competitive intelligence, market dynamics, customer needs across segments, local market access, etc.

New!

Miami, FL2 days ago

The Account Manager plays a critical role in owning and advancing B2B relationships within the largest and most complex healthcare delivery networks, including health systems (HSs), Integrated Delivery Networks (IDNs), state CDC awardees, major health departments, and other large institutional accounts. Serving as the primary customer liaison, this role engages HCPs, senior-level clinical and non-clinical stakeholders to understand customer priorities, address unmet needs, and deliver customized, data-driven value propositions.

Doral, FL30+ days ago

The Director, Clinical Performance is responsible for the management of clinical capabilities related to Delegated Utilization Management and Delegated Care Management across multiple health plan clients in the California Medi-Cal, Medicaid delegated services markets. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.

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Utilization Management Nurse Jobs in Miami, FL

Medical Director of Case Management and Utilization Review - FT Days ? MHM Memorial Healthcare System

Case Manager, RN Memorial Healthcare System

Case Manager - RN - Per Diem Memorial Healthcare System

Clinical Appeals Nurse Health Business Solutions LLC

RN Case Mgr HCA Healthcare

RN Case Manager PRN HCA Healthcare

Nurse Case Manager GMMI, Inc.

Bilingual Clinical Nurse Navigator (RN) Renalogic

RN Case Manager, Full Time, Day shift and flexible weekend Job ID 1560329 Palmetto General Hospital

LPN Care Coordinator (BHI) MedElite Group, LLC.

Registered Nurse (Transitions of Care) Integrated Resources, Inc

Registered Nurse Case Manager HCA Healthcare

Dialysis RN (PRN) Aptive

Dialysis Registered Nurse Aptive

Oncology Clinical Nurse Educator Syneos - Commercial - Prod

Manager, Clinical Appeals Health Business Solutions LLC

Client Service Manager, Government – Miami, FL GetWellNetwork, Inc.

MDS Care Plan Coordinator Plantation Nursing and Rehabilitation Center

Clinical Rehab Specialist PRN HCA Healthcare

Clinical Rehab Specialist HCA Healthcare

Grievance & Appeals Coordinator Alivi

Director of Respiratory Therapy Plantation Nursing and Rehabilitation Center

AVP, Clinical Performance NeueHealth

Hematology Account Manager - Miami, FL PharmaEssentia U.S.A.

Territory Account Manager Syneos - Commercial - Prod

Director, Clinical Performance NeueHealth

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