Pool Utilization Review Registered Nurse, Case Management, Per Diem, Shift Varies (Rotating Weekends)

Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 29,000 employees, 4,500 physicians, and 200 outpatient centers, urgent care facilities, and physician practices across Miami-Dade, Monroe, Broward, and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 26 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2025-2026 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 63 high-performing honors.

About the role

The purpose of this position is to conduct initial, concurrent, and retrospective chart review for clinical, financial, and resource utilization. Coordinates with the healthcare team for optimal, efficient patient outcomes while decreasing length of stay and avoiding delays and denied days. Accountable for a designated patient caseload and provides intervention and coordination to decrease avoidable delays and denial of reimbursement.

Responsibilities

• Screens pre-admission and admission processes using established criteria for all points of entry.
• Facilitates communication between payers, review agencies, and the healthcare team.
• Identifies delays in treatment or inappropriate utilization and serves as a resource.
• Coordinates communication with physicians.
• Identifies opportunities for expedited appeals and collaborates to resolve payer issues.
• Ensures and maintains effective communication with Revenue Cycle Departments.

Requirements

• Associate’s Degree in Nursing (BSN required for new hires).
• Registered Nurse (RN) license.
• RNs hired prior to 2/2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associate’s Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN; however, they must complete the BSN within 3 years of hire.
• 3 years of hospital clinical experience preferred.
• 1 year of Hospital or Payor Utilization Review experience required.
• MCG Specialist Certification ISC/HRC required within 12 months of job entry date.

Skills

• Excellent written, interpersonal communication, and negotiation skills.
• Strong critical thinking skills and the ability to perform clinical chart review and abstract information efficiently.
• Strong analytical, data management, and computer skills.
• Strong organizational and time management skills, with the capacity to prioritize multiple tasks.
• Current working knowledge of payer and managed care reimbursement preferred.
• Ability to work independently and exercise sound judgment in interactions with the healthcare team and patients/families.
• Knowledgeable in local, state, and federal legislation and regulations.
• Ability to tolerate high-volume production standards.

Benefits

• Career growth and development opportunities, with clear pathways and ongoing support.
• Comprehensive health and wellness resources that go beyond traditional benefits.
• A wellness program that can help employees eliminate their medical plan deductible, reducing out-of-pocket healthcare costs.
• Tuition reimbursement to support continued learning and advancement.

Pay

Estimated pay range for this position is $47.00 per hour, depending on shift as applicable.