Trinity Health·Fort Lauderdale, Florida
The Utilization Review Nurse assesses patient care plans and medical records to verify the necessity and effectiveness of treatments. They ensure appropriate admission status and coordinate authorizations with managed care companies using MCG/InterQual criteria.
Part time
Shift:
Description: The Utilization Review (UR) Nurse has well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the department by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers. ***Hybrid Position**
Position
Purpose: Utilization Review (UR) Nurses play a vital role in healthcare by making sure that patients receive appropriate care while managing healthcare costs effectively. They assess patient care plans and medical records to verify the necessity and effectiveness of the treatments being proposed or provided.
What you will do: *Reviews hospital admissions to ensure appropriate admission status in accordance with MCG/InterQual criteria and to assure that the physician admits patient under the guidelines of the Managed Care Companies thus facilitating the authorizations. *Monitors on an on-going basis case assignment for Managed Care Companies authorization of hospital stay. *Reviews urgent cases authorized for one day within 24 hours of admission. Reviews concurrent cases and discharge plans in timeframes determined in the review process with external entities. *Provides clinical data as part of the telephonic or electronic review process to external parties (as required) to ensure continued stay authorizations. *Coordinates Physician Advisor referrals with there are concerns regarding meeting level of care criteria (utilizing Indicia/InterQual). Reviews PA referrals with department manager as needed.
*Ensure Observation services begin when care is initiated in accordance with the physician’s order for patients placed in observation, from the ED or as directed admit. This time will be identified by the time the order for Observation is written by the attending physician. Extended Recovery services begin after an ambulatory surgery patient arrives on the unit after the routine period ends.
• Graduate of an accredited school of professional nursing.
Candidates must be a graduate of an accredited professional nursing school and hold a valid RN license in the State of Florida. A Bachelor of Science in Nursing (BSN) is preferred.
Market context
Utilization review RN roles in Florida are often sought by employers managing care coordination, authorization, and medical necessity review across settings. This role can be competitive because it is hybrid and per-diem, and candidates with an active Florida RN license plus a BSN may stand out. Review the employer’s documentation expectations and be ready to show experience with utilization review, chart review, and payer communication; the requirements and benefits here are AI-summarized from the original job description, saving you research time.
