Behavioral Health Utilization Review Nurse

Behavioral Health Utilization Review Nurse

The Utilization Management Nurse (UMN) plays a crucial role in reviewing requests for service authorizations to ensure the appropriate use of services. Under the general supervision of the Director and/or Manager/Supervisor of Medical Management, and in collaboration with the interdisciplinary team, the UMN handles tasks related to utilization review across various specialties, medical treatments, and services. The role involves managing complex cases, developing internal processes, and closely interacting with Medical Directors and other staff to ensure proper utilization and data capture. Furthermore, the UMN provides education on issues related to utilization review and ensures smooth transitions of care, maintaining high provider and patient satisfaction.

Responsibilities

• Review prior authorization requests for medical necessity and appropriateness, using standardized Review Criteria.
• Coordinate with Medical Director/Physicians for requests outside of standard Review Criteria.
• Maintain compliance with federal and state guidelines as well as contractual requirements.
• Obtain necessary documentation and ensure completion of assigned caseload.
• Serve as a liaison between Medical Director, physicians, and office staff to resolve prior authorization issues.
• Communicate denial determinations to providers when necessary.
• Perform evaluation and concurrent monitoring of resource utilization, including durable medical equipment and long-term rehabilitation.
• Provide timely documentation reflecting department work processes and policy guidelines.
• Promote safe and appropriate coordination of care and optimal utilization of resources.
• Identify and participate in the development of programs, policies, and procedures for continuous quality improvement.
• Ensure adherence to company and department policies regarding confidentiality.
• Participate in regular departmental training.
• Serve as a plan liaison to coordinate enrollee benefits with providers and/or external organizations.
• Prepare and present reports on department activities as assigned.

Essential Skills

• Experience in utilization management, behavioral health, and mental health.
• Proficiency in clinical and utilization review processes.
• Current unrestricted Florida RN or LPN License.
• Minimum one year of utilization review experience.
• Minimum one year of experience in discharge planning in an acute care setting.
• Four years related clinical experience in healthcare or equivalent education and experience.

Additional Skills & Qualifications

• Valid Florida Driver's License.
• Knowledge of case management and utilization review concepts, including InterQual and Milliman Criteria.
• Understanding of Florida Medicaid Program and CMS Guidelines.
• Familiarity with community and post-acute resources.
• Proficient in word processing software, spreadsheet software like Microsoft Excel, and electronic medical record software.

Work Environment

This position offers a hybrid work schedule, with in-office work in Sunrise on Tuesdays from 8:30 AM to 5:00 PM, including a 30-minute lunch break. Training will take between 2-4 weeks, during which the new team member will shadow a colleague on-site on Tuesdays and will be logged into Teams for remote shadowing.

Job Type & Location

This is a Contract to Hire position based out of Sunrise, Florida.

Pay and Benefits

The pay range for this position is $35.00 - $38.00/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 Oct 15, 2025.