Qualifications

• Licensed Registered Nurse in Florida required, with credentials from the Florida Board of Nursing prior to hire or transfer.
• Diploma from an accredited nursing school or equivalent professional licensure at the time of hire required.
• 3+ years of clinical experience preferred, with a focus on Observation.
• Experience in Utilization Management, Case Management, or Care Coordination is a plus.
• Prior experience in a remote work setting is desirable.

Responsibilities

• Perform reviews of admissions and service requests to ensure medical necessity using evidence-based criteria.
• Manage complex cases by coordinating with the multidisciplinary team to align care with clinical status and protocols.
• Oversee compliance with federal and third-party payer regulations to mitigate financial risk.
• Assist staff with precertification, coding, and managing claim denials or appeals.
• Lead discharge planning efforts to ensure safe patient transitions and prepare reports on resource utilization trends.

Benefits

• Remote work flexibility allows for a better work-life balance.
• Full-time position with scheduled daytime hours.
• Opportunity to work in a multidisciplinary team environment, fostering collaboration.
• Potential for professional growth in Utilization Review and Case Management.