Top 42 Utilization review nurse Jobs in Miami, Fl

Care Review Clinician (BH Licensed) - Remote in FL
Molina Healthcare, Inc. —Miami, FL
- $26.41 - $51.49 an hour
- Full-time
- Remote
- LMFT
- Licensed Clinical Social Worker
- Mid-level
- Health insurance
Care Review Clinician (BH Licensed) - Remote in FL
Molina Healthcare, Inc. —Florida
- $26.41 - $51.49 an hour
- Full-time
- Remote
- LMFT
- Licensed Clinical Social Worker
- Mid-level
- Health insurance
Care Review Clinician (RN) - Remote in FL
Molina Healthcare, Inc. —Miami, FL
- $26.41 - $51.49 an hour
- Full-time
- Remote
- RN License
- Mid-level
- Critical & Intensive Care
- Health insurance
Care Review Clinician (RN) - Remote in FL
Molina Healthcare, Inc. —Florida
- $26.41 - $51.49 an hour
- Full-time
- Remote
- RN License
- Mid-level
- Critical & Intensive Care
- Health insurance
Home Health Wound Care RN
OneHome —Miramar, FL
- $77,200 - $106,200 a year
- Full-time
- RN License
- Home Health
- Senior level
- Paid parental leave
- Paid holidays
1d
Utilization Review Nurse
Oscar Health —Miami, FL
- $35.00 - $45.94 an hour
- Weekends as needed
- Remote
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Paid holidays
Quick Apply
10d
Care Review Clinician, Specialty Therapist (Occupational / Physical / Speech) - REMOTE
Molina Healthcare —Miami, FL
- $26.41 - $51.49 an hour
- Full-time
- Remote
- Physical & Rehabilitation Medicine
- Mid-level
- Physical Therapy License
- Health insurance
10d
Sr. Quality of Care Review Nurse
Oscar Health —Miami, FL
- $83,628.00 - $109,761.75 a year
- Remote
- Spanish
- Nursing
- RN License
- Paid parental leave
- Paid holidays
Quick Apply
5d
Utilization Review Nurse
FLORIDA PACE CENTERS, INC. —Miami, FL
- Weekends as needed
- Remote
- Acute care
- Background check
- Nursing
- Free parking
- Health insurance
Quick Apply
Medical Review Nurse - CMS RAC (Government audits)
Performant Financial Corporation —Plantation, FL
- $81,000 - $90,000 a year
- Full-time
- Remote
- RN License
- Computer literacy
- Writing skills
- Health savings account
- Paid holidays
Concurrent Review Nurse (Weekend Shift)
Leon Health —Miami-Dade County, FL
- Full-time
- Hybrid work
- Spanish
- Nursing
- English
Quick Apply
Utilization Review
Westchester General Hospital —Miami, FL
- Overtime
- Nursing
- RN License
- Hospital
Quick Apply
5d
Case Manager
West Gables Rehabilitation Hospital —Miami, FL
- $75,000 - $112,000 a year
- Full-time
- Hospital
- Inpatient
- Mid-level
- Dental insurance
- Paid time off
Quick Apply
Registered Nurse Utilization Review, Case Management
South Miami Hospital —South Miami, FL
- $73,860.80 - $98,234.86 a year
- Nursing
- RN License
- Mid-level
- Wellness program
- Health insurance
Medical Review Clinical Appeals Auditor (RN)
Performant Financial Corporation —Plantation, FL
- $80,000 - $90,000 a year
- Full-time
- Microsoft Excel
- RN License
- Computer literacy
- Health savings account
- Paid holidays
Case Management RN
Sanitas Medical Center —Doral, FL
- Full-time
- Spanish
- Master of Social Work
- Nursing
Quick Apply
12d
Clinical Care Coordinator, Full-Time, 7a-7:30pm
Jackson Health —Miami, FL
- 12 hour shift
- Nursing
- Psychiatry
- RN License
Quick Apply
Clinical Documentation Integrity - Second Level Reviewer
University of Miami —Hialeah, FL
- Full-time
- Remote
- Nursing
- Medicine
- Microsoft Excel
- Health insurance
- Dental insurance
Nurse Case Manager
Battelle —Homestead, FL
- Full-time
- Hybrid work
- Nursing
- RN License
- BLS Certification
- Wellness program
- Health insurance
Case Manager - Inpatient Rehab
Select Medical Rehabilitation - Miami Lakes —Miami Lakes, FL
- Full-time
- Hospital
- Inpatient
- Mid-level
- Dental insurance
- Paid time off
Quick Apply

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utilization review nurse jobs near miami, fl

Care Review Clinician (BH Licensed) - Remote in FL

Molina Healthcare, Inc. -
Miami, FL

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Job Details

Full-time
$26.41 - $51.49 an hour

Benefits

Health insurance

Qualifications

Productivity software

Full Job Description

JOB DESCRIPTION Job Summary

Provides support for member clinical service review processes specific to behavioral health. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, and ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

Assesses services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
Conducts reviews to determine prior authorization / financial responsibility for Molina and its members.
Processes requests within required timelines.
Refers appropriate cases to medical directors and presents cases in a consistent and efficient manner.
Requests additional information from members or providers as needed.
Makes appropriate referrals to other clinical programs.
Collaborates with multidisciplinary teams to promote Molina care model.
Adheres to utilization management (UM) policies and procedures.
May work collaboratively with appropriate departments to provide applied behavior analysis (ABA)/behavioral health therapy (BHT) services to Molina members with autism spectrum disorder (ASD) and other related disorders.
May approve requests for BHT by reviewing behavioral assessments and treatment plans for medical necessity and BHT best practice guidelines. This includes but is not limited to: psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports.
May perform ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy.
May provide peer to peer consultation BHT in-network providers to support treatment planning and maximize member progress.
May work collaboratively with ABA providers to ensure best service practices for members.
May create and develops forms, recommendations and guidelines and training for BHT service delivery.
May collaborate and coordinate with behavioral health medical directors, and senior medical directors to ensure proper management of the BHT benefit.

Required Qualifications

At least 2 years health care experience, including experience in behavioral health and/or hospital acute care, or equivalent combination of relevant education and experience.
Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), Licensed Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC), Licensed Marriage and Family Therapist (LMFT) or equivalent behavioral health licensure. License must be active and unrestricted in state of practice.
May require behavioral analyst experience, and/or board certification/licensure as a behavioral analyst (BCBA and/or LBA).
Demonstrated knowledge of community resources.
Ability to operate proactively and demonstrate detail-oriented work.
Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
Ability to work independently, with minimal supervision and demonstrate self-motivation.
Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
Excellent problem-solving, and critical-thinking skills.
Strong verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

Recent hospital behavioral health experience in an intensive care unit (ICU) or emergency room.

#PJHS3

#LI-AC1

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Apply Now

Refine Your Search

utilization review nurse jobs in miami, fl

Care Review Clinician (BH Licensed) - Remote in FL

Care Review Clinician (BH Licensed) - Remote in FL

Care Review Clinician (RN) - Remote in FL

Care Review Clinician (RN) - Remote in FL

Home Health Wound Care RN

Utilization Review Nurse

Care Review Clinician, Specialty Therapist (Occupational / Physical / Speech) - REMOTE

Sr. Quality of Care Review Nurse

Utilization Review Nurse

Medical Review Nurse - CMS RAC (Government audits)

Concurrent Review Nurse (Weekend Shift)

Utilization Review

Case Manager

Registered Nurse Utilization Review, Case Management

Medical Review Clinical Appeals Auditor (RN)

Case Management RN

Clinical Care Coordinator, Full-Time, 7a-7:30pm

Clinical Documentation Integrity - Second Level Reviewer

Nurse Case Manager

Case Manager - Inpatient Rehab

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