Palm Medical Centers·Coral Gables, Florida
The Concurrent Review Nurse performs utilization management by reviewing inpatient admissions to ensure medical necessity and appropriate care. They collaborate with healthcare providers and payers to coordinate patient care while documenting all decisions according to regulatory standards.
The Concurrent Review Nurse is responsible for performing utilization management activities to ensure medical services are delivered effectively, efficiently, and appropriately. This includes reviewing inpatient admissions and ongoing hospital stays to determine medical necessity, appropriateness of care, and length of stay in accordance with clinical guidelines and payer requirements.
Conduct timely and accurate concurrent reviews of inpatient hospitalizations and other levels of care. Evaluate clinical documentation against evidence-based criteria (e.g., InterQual®, MCG) to determine medical necessity and appropriate level of care. Collaborate with physicians, hospital staff, and insurance companies to coordinate patient care and discharge planning. Communicate utilization review decisions and recommendations to providers and payers. Document all reviews, decisions, and communications in accordance with regulatory and organizational standards. Identify cases requiring escalation or peer review and follow established procedures. Ensure compliance with CMS guidelines, accreditation standards (e.g., NCQA, URAC), and HIPAA. Participate in quality improvement initiatives and departmental meetings
Registered Nurse (RN) license, active and in good standing, required. Associate or Bachelor’s degree in nursing (BSN preferred).
Palm Medical Centers is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. Palm Medical Centers makes hiring decisions based solely on qualifications, merit, and business needs at the time.
Candidates must hold an active Registered Nurse (RN) license and have at least two years of clinical experience. Proficiency in clinical review guidelines like InterQual or MCG and familiarity with insurance regulations are required.
Market context
In Florida, nursing roles are typically in steady demand across hospice, hospital, and other care settings, especially for RNs who can work independently and adapt to varied patient needs. These positions are competitive because employers often look for current RN licensure, at least one year of experience, active BLS certification, and reliable transportation, while benefits commonly include health insurance, professional development, and a supportive work environment. Before applying, confirm your license, BLS status, and driving readiness, and review the AI-summarized requirements and benefits here to save time versus reading the full original posting.
