Utilization Review Nurse

Job Summary

The Utilization Nurse is responsible for conducting prospective, concurrent, and retrospective clinical reviews to determine medical necessity, level of care, and appropriateness of services across the continuum. This role collaborates closely with hospital UR/Case Management, facility and community providers, and the Interdisciplinary Team (IDT) to facilitate timely care transitions, prevent avoidable days, and ensure members receive only medically necessary services in accordance with evidence-based criteria, payer policies, and regulatory requirements. The Utilization Nurse communicates authorization decisions and care progression, coordinates documentation exchange, and maintains comprehensive, audit-ready records. All utilization management activities are performed in accordance with CMS PACE regulations (42 CFR Part 460) and are intended to support—rather than replace—the clinical decision-making authority of the PACE Interdisciplinary Team (IDT).

Essential Job Functions

• Performs admission, continued stay, and discharge reviews for inpatient, observation, post-acute (SNF, IRF, LTACH), home health, DME, and outpatient services.

• Applies evidence-based criteria (e.g., InterQual/MCG) and health plan policies to determine medical necessity and level of care; document detailed clinical rationales supporting approvals or non-authorizations.

• Issues and communicates authorization decisions within required turnaround times; escalates complex cases to a Medical Director per policy.

• Identifies avoidable days and collaborates with providers to resolve barriers to progression of care and discharge.

• Travels to different acute care hospitals in the area to meet case managers and hospitalists to plan participant discharge in a timely and organized manner.

Clinical Judgment & Evidence-Based Decision-Making

Utilizes clinical judgment and evidence-based decision-making to determine medical necessity and level of care.

Negotiation & Collaborative Problem-Solving

Works collaboratively with providers to resolve issues and ensure timely care transitions.

Attention to Detail & Audit-Ready Documentation

Maintains complete, accurate, and audit-ready documentation of all utilization review activities in the UM platform.

Communication & Member/Provider Experience

• Communicates determinations with clarity, professionalism, empathy, and provides education on criteria and required clinicals.

• Supports appeals and grievances with organized, evidence-based clinical summaries.

Quality Improvement & Performance

• Tracks and helps improve key outcomes, such as avoidable days, readmission risk, LOS variance, denial overturn rates, and provider satisfaction.

• Participates in case rounds, inter-rater reliability reviews, and continuous improvement initiatives.

Technology & Tools

• Navigates electronic medical records (EMRs), UM platforms, eligibility/benefits systems, and secures messaging tools to obtain and share clinical documentation.

• Uses standard office tools (e.g., Outlook, Excel, Word) to organize caseloads, track follow-ups, and report performance.

Job Requirements

• Education: Graduate from an accredited Nursing program.

• Experience: 2–4 years of experience in healthcare administration, utilization management, or a related operational role. 2+ years of recent clinical experience in acute care, post-acute, emergency/observation, or related settings with strong assessment skills. Prior Utilization Management/Review or Managed Care experience (payer, IPA, ACO, or delegated UM).

• Licenses/Certifications: Current RN or LPN license by the Florida State Board of Nursing. CCM, CPUR, CPHQ, ACM-RN, or equivalent preferred.

• Abilities Required: Clinical judgment and evidence-based decision-making. Strong negotiation and collaborative problem-solving skills when working with providers. High attention to detail and ability to produce audit-ready documentation. Effective time management, prioritization, and adherence to turnaround times (TAT). Professional, clear, and empathetic verbal and written communication skills. Strict adherence to HIPAA, as well as all company privacy and security policies. Ability to maintain the confidentiality of member information. Ability to complete all required compliance trainings and participate in internal and external audits. Demonstrated ability to interpret clinical documentation and synthesize information to make evidence-based medical necessity determinations. Ability to sit for extended periods and manage prolonged screen time. Ability to travel when needed for trainings, meetings, or audits. Ability to meet coverage needs (evenings/weekends/holidays as required by census and regulatory timelines). Ability to collaborate effectively with hospital UR/CM and multidisciplinary teams in a fast-paced environment. Proficiency with EMR records, UM systems, and Microsoft Office (Word, Excel, Outlook). Knowledge of ICD-10, CPT/HCPCS, DRGs, and documentation requirements that support medical necessity. Familiarity with InterQual/MCG criteria, coverage policies, and Medicare Advantage/Medicaid requirements.

Functional Demands

• Work Conditions: Remote role with reliable high-speed internet. Infectious Material Exposure N/A.

• Organizational Expectations: Ensures that resident’s/patient’s rights are adhered to. Demonstrates professionalism and accountability. Demonstrates a caring attitude consistent with Miami Jewish EmpathicareSM toward MJH residents, patients, family members, employees, and other facility guests. Demonstrates excellent communication skills. Ensures confidentiality and security of patients’ medical information. Identifies and utilizes appropriate channels of communication. Able to speak, read and write English. Able to think and act calmly to meet unusual occurrences of the job. Adheres to the organization’s Mission, Vision and Values. Participates in departmental activities, meetings and in-services and follows established guidelines. Maintains a safe working environment.