• Utilization Management Nurse

    Actalent (Sunrise, FL)


    Actalent is hiring UM nurses!Job Description

     

    The Utilization Management Nurse (UMN) plays a crucial role in optimizing the utilization of healthcare services. Working under the general supervision of the Director and/or Manager/Supervisor of Medical Management, and in collaboration with an interdisciplinary team, the UMN reviews service authorization requests to ensure appropriate service utilization. This includes reviewing specialties, medical treatments, elective hospital admissions, rehabilitative services, home care, and out-of-plan referrals. The UMN also assists with complex cases, internal process development, and educates physicians and team members on utilization review issues. Ensuring smooth transitions and patient satisfaction is key to this role.

    Responsibilities

    + Review prior authorization requests for medical necessity and appropriateness using standardized criteria.

    + Coordinate with Medical Directors/Physicians for requests outside of standard criteria.

    + Ensure compliance with federal, state, and contractual guidelines.

    + Manage caseload by obtaining necessary documentation and addressing discrepancies.

    + Serve as a liaison between Medical Directors, physicians, and office staff.

    + Perform evaluation and monitoring of resource utilization such as durable medical equipment and hospitalizations.

    + Document department work processes and policy guidelines.

    + Promote safe and appropriate coordination of care.

    + Identify and develop programs, policies, and procedures for continuous quality improvement.

    + Maintain confidentiality according to company and department policies.

    + Participate in regular departmental training sessions.

    + Coordinate enrollee benefits with providers and external organizations.

    + Prepare and present reports on department activities.

    Essential Skills

    + Clinical review

    + Utilization review

    + Utilization management

    + Interqual

    + Milliman Commercial Guidelines

    + Medicaid

    + Medical management

    + Medicare

    + Managed care

    + Patient care

    + Medical record management

    Additional Skills & Qualifications

    + Current unrestricted Florida RN or LPN License

    + Minimum of two years of utilization review experience

    + Minimum of one year of discharge planning experience in an acute care setting

    + Four years of related clinical experience in a healthcare field or equivalent education

    + Valid Florida Driver’s License

    + Knowledge of case management and utilization review concepts

    + Familiarity with Florida Medicaid Program and CMS Guidelines

    + Proficiency in word processing software, Microsoft Excel, and electronic medical record software

     

    Work Environment

     

    The role offers a hybrid work schedule post-training, with hours from Monday to Friday, 8am-5pm.

    Pay and Benefits

    The pay range for this position is $35.00 - $35.00/hr.

     

    Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

     

    • Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

     

    Workplace Type

     

    This is a hybrid position in Sunrise,FL.

     

    Application Deadline

     

    This position is anticipated to close on Jun 6, 2025.

    About Actalent

    Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

     

    The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

     

    If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [email protected] (%[email protected]) for other accommodation options.