Top 14 Utilization review nurse Jobs in Melbourne Fl

Utilization Management Nurse - Case Management
Health First Careers —Melbourne, FL
- Full-time
- Nursing
- RN License
- 5 years
- Health insurance
Senior Clinical Reviewer
Christian Care Ministry —Rockledge, FL
- $31.97 - $43.51 an hour
- Full-time
- 18 years or older
- Anatomy knowledge
- Microsoft Excel
- Paid parental leave
- Health savings account
5d
Transfer Access RN Case Manager - Access Center
Health First Careers —Palm Bay, FL
- Per diem
- Nursing
- RN License
- Customer service
- Health insurance
- Vision insurance
9d
Oncology RN Care Manager
Christian Care Ministry —Melbourne, FL
- $74,500 - $101,500 a year
- Full-time
- 18 years or older
- Nursing
- Microsoft Excel
- Paid parental leave
- Health savings account
Medical Review Nurse (USACE)
Acuity International —Cape Canaveral, FL
- $66,560 - $70,000 a year
- Full-time
- Nursing
- RN License
- 5 years
Quick Apply
Unit Manager - RN
West Melbourne Health And Rehabilitation Center —West Melbourne, FL
- Full-time
- Skilled nursing facility
- RN License
- Mid-level
- Paid holidays
- Health insurance
Quick Apply
2d
Medical Field Case Manager
Enlyte —Melbourne, FL
- $70,600 - $90,000 a year
- Full-time
- Nursing
- Microsoft Outlook
- RN License
- Travel reimbursement
- Health savings account
5d

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Case Manager - RN
Hines & Associates Inc —United States
Hines and Associates only hires licensed/certified medical professionals with an unrestricted license/certification in the state or in a state that has…
$60,000 - $66,000 a year
Quick Apply

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Case Manager (RN) - Full-Time
OhioHealth Rehabilitation Hospital —Columbus, OH
Current Licensure per state guidelines in clinical or related discipline OR a Bachelor's or Master's in a health or human services discipline.
$70,000 - $84,000 a year
Quick Apply
5d
Utilization Review Specialist - Autism
Nationwide Children's Hospital —Columbus, OH
Bachelor’s Degree in Social Work, Psychology, or related field, required. Documents all case reviews and maintains accurate records of all clinical activities…

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Utilization Management Nurse - Case Management

Health First Careers -
Melbourne, FL

Apply Now

Job Details

Full-time

Benefits

Health insurance

Qualifications

RN License
BLS Certification
Acute care facility experience
Data management
Computer skills

Full Job Description

Job Requirements

POSITION SUMMARY

The Utilization Management (UM) Nurse performs medical necessity reviews on all payer admissions to determine appropriate admission status and documents all information that relates to insurance reimbursement in appropriate reviews for the Health First Integrated Delivery Network (IDN). The UM Nurse utilizes advanced clinical skills to facilitate the provision of care including the appropriate length of stay, patient status management, and resource utilization for all hospital admissions. The UM Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment and regularly collaborates with the Medical Staff, Physician Advisors, Case Managers, Revenue Cycle and other multi-disciplinary teams.

PRIMARY ACCOUNTABILITIES

Evaluates admissions, continued stays, and services with evidence-based criteria (e.g., InterQual, MCG).
Determines whether care is medically necessary, appropriate, and at the right level of care, and identifies over-utilization and under-utilization.
Verifies compliance with Centers For Medicare and Medicaid Services (CMS) Conditions of Participation, Medicare and Medicaid rules, and Commercial payer requirements.
Maintains accurate, defensible documentation, and supports audits and accreditation standards (e.g., Joint Commission, CMS).
Reviews prior authorizations and concurrent approvals, initiating peer-to-peer reviews when criteria are not met, and manages denials, appeals, and retrospective reviews.
Communicates decisions clearly to providers and stakeholders.
Collaborates closely with licensed practitioners and advanced practice providers, case managers and social workers, coding, billing, and finance teams
Advocates for patients while balancing payer requirements, and promotes efficient, timely progression of care.
Supports appropriate resource utilization without compromising quality.
Identifies opportunities for alternative levels of care (OBS vs IP, SNF, home health, etc.), early discharge planning, while contributing to organizational goals around quality metrics and cost containment.

Work Experience

MINIMUM QUALIFICATIONS

Education: Associate’s degree in Nursing (ASN), or Nursing Diploma.
Work Experience: Five (5) years’ experience in acute care (e.g., critical, intermediate, or emergency department) nursing environments.
Licensure: Registered Nurse (RN) licensure in the State of Florida, or endorsement.
Certification: American Heart Association Basic Life Support (AHA BLS) Healthcare Provider Completion Card prior to start date and maintained.
Skills/Knowledge/Abilities:

Strong analytical, data management and computer skills.
Ability to work autonomously and prioritize multiple tasks and role components.
Ability to exercise sound judgment in interactions with physicians, payers, and
other customers.
Must be able to work remotely with adequate technology to support and
maintain productivity.

PREFERRED QUALIFICATIONS

Education: BSN or Master’s Degree in a healthcare field
Certification: Current Case Manager Certification (CCM or ACM)
Knowledge/Skills/Abilities: Current working knowledge of care transitions, utilization management, case management and managed care reimbursement

PHYSICAL REQUIREMENTS

Majority of time involves sitting or standing; occasional walking, bending, and stooping.
Long periods of computer time or at workstation.
Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
Communicating with others to exchange information.
Visual acuity and hand-eye coordination to perform tasks.
Workspace may vary from open to confined.
May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

Benefits

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.

Schedule : Full-Time

Shift Times : 830am_500pm

Paygrade : PG-PG-39

Apply Now

Refine Your Search

utilization review nurse jobs in melbourne fl

Utilization Management Nurse - Case Management

Senior Clinical Reviewer

Transfer Access RN Case Manager - Access Center

Oncology RN Care Manager

Medical Review Nurse (USACE)

Unit Manager - RN

Medical Field Case Manager

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