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Prior Authorization Utilization Review Jobs in Florida

Enlyte

Utilization Reviewer 2

Tampa, FL

$59K - $76K/yr

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity. * Prior experience in the workers' compensations field. Benefits We're ...

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Prior Authorization Utilization Review information

What is a Prior Authorization Utilization Review specialist?

A Prior Authorization Utilization Review specialist is a healthcare professional responsible for evaluating medical service requests to ensure they meet specific criteria for approval before services are provided. Their main role is to review clinical information, verify medical necessity, and ensure compliance with insurance policies and guidelines. They act as a liaison between healthcare providers, insurance companies, and patients to facilitate timely and accurate authorization decisions. This process helps to manage healthcare costs and ensure patients receive appropriate care.

What are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review specialist?

To thrive as a Prior Authorization Utilization Review Specialist, you need a strong understanding of medical terminology, insurance guidelines, and clinical criteria, often supported by a degree in healthcare or nursing and relevant certification (such as RN or LPN). Familiarity with prior authorization software, electronic health record (EHR) systems, and payer portals is typically required. Attention to detail, strong communication skills, and the ability to multitask help professionals excel in this role. These competencies ensure accurate and timely processing of authorizations, reducing delays in patient care and ensuring compliance with payer requirements.

What are some common challenges faced by professionals in Prior Authorization Utilization Review roles, and how can these be managed?

Professionals in Prior Authorization Utilization Review often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and ensuring timely communication between providers and payers. Staying organized, developing a thorough understanding of payer guidelines, and maintaining clear, consistent communication are key strategies for managing these challenges. Many teams also rely on workflow management tools and regular team huddles to streamline processes and ensure all cases are handled efficiently.

What is the difference between Prior Authorization Utilization Review vs Medical Reviewer?

AspectPrior Authorization Utilization ReviewMedical Reviewer
CredentialsLicensed healthcare professionals, often with certifications in utilization reviewLicensed physicians or healthcare providers with clinical expertise
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, clinics, insurance companies, or consulting firms
Primary FocusAssessing the necessity of procedures or treatments before approvalEvaluating clinical records to determine medical necessity and appropriateness

While both roles involve clinical assessment, Prior Authorization Utilization Review focuses on pre-authorization decisions for treatments, whereas Medical Review involves detailed clinical evaluation of patient records to determine medical necessity. Both require healthcare credentials and are integral to healthcare quality and cost management.

What are popular job titles related to Prior Authorization Utilization Review jobs in Florida?

For Prior Authorization Utilization Review jobs in Florida, the most frequently searched job titles are:

What job categories do people searching Prior Authorization Utilization Review jobs in Florida look for?

The top searched job categories for Prior Authorization Utilization Review jobs in Florida are:

What cities in Florida are hiring for Prior Authorization Utilization Review jobs?

Cities in Florida with the most Prior Authorization Utilization Review job openings:

Prior Authorization Utilization Review jobs near you
Infographic showing various Prior Authorization Utilization Review job openings in Florida as of August 2026, with employment types broken down into 50% Full Time, and 50% Part Time. Highlights an 100% In-person job distribution.

Senior Utilization Review Specialist - Part Time

Sage Clinical RCM, LLC

Gulfport, FL • On-site

Part-time

Posted 16 days ago

Job description

Description: Position Summary

The Part Time Senior Utilization Review Specialist is an experienced registered nurse responsible for concurrent and retrospective review of hospital services to support appropriate utilization, accurate patient status, timely payer authorization, and medical necessity compliance. This senior individual-contributor role serves as a clinical resource for complex cases and partners with physicians, care management, patient access, coding, and revenue cycle teams to reduce avoidable denials and support appropriate reimbursement.

Key Responsibilities

• Perform concurrent and retrospective utilization review for assigned inpatient, observation, and outpatient cases using approved criteria, payer policies, and clinical judgment.

• Apply InterQual, MCG, or client-approved criteria to support medical necessity, level of care, continued stay, and patient-status determinations.

• Obtain, submit, and track payer notifications and authorizations; communicate clinically relevant information to payer medical-management teams within required time frames.

• Identify potential medical-necessity, authorization, status, and documentation risks early and escalate appropriately to prevent avoidable denials.

• Collaborate with physicians, case management, CDI, coding, patient access, and revenue cycle partners to clarify documentation and support appropriate care progression.

• Coordinate clinical information and deadlines for peer-to-peer review or denial escalation when needed; maintain complete, accurate documentation in the designated systems.

• Serves as a member of the Utilization Review Committee-prepares reports to include utilization trends, denial patterns, extended stays, and workflow barriers; communicate actionable findings to leadership.

• Performs escalations to UR Committee members to ensure that compliance with regulations for patient status changes by providers are occurring per policy. Documents escalations and presents outcomes to UR committee.

• Serve as a senior clinical resource, providing guidance and support on complex review questions while adhering to established policies and escalation pathways.

• Participate in quality audits, education, process improvement, and other initiatives that strengthen utilization management performance.

Requirements: Required Qualifications

• Current, unrestricted RN license.

• Five or more years of acute-care hospital experience, including at least three years in utilization review, utilization management, case management, or a closely related function.

• Demonstrated experience applying medical-necessity and level-of-care criteria, including concurrent review and continued-stay review.

• Working knowledge of inpatient versus observation status, payer authorization requirements, Medicare and managed-care utilization principles, and denial-prevention practices.

• Strong clinical judgment, prioritization, documentation, communication, and collaborative problem-solving skills.

• Ability to independently manage a high-volume, deadline-driven caseload while exercising sound judgment regarding escalation.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN).

• Certification in case management or utilization management, such as CCM or ACM.

• Experience with InterQual, MCG, Cerner, or comparable utilization-management and electronic health-record systems.

• Experience supporting hospital denials management, peer-to-peer coordination, or care-progression initiatives.


Role Boundaries and Work Expectations

• This is a senior individual-contributor role and does not include direct people management unless separately assigned.

• The specialist follows St. John's Health clinical policies, payer requirements, and established Sage Clinical RCM workflows.

• The role requires discretion with protected health information and strict compliance with HIPAA, client security standards, and applicable regulations.

• Availability during agreed hospital business hours and participation in required meetings, education, and workflow updates are expected.