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Utilization Management Associate Jobs in Hialeah, FL

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Senior Registered Nurse

Miami, FL · On-site

... of the Utilization Management process(es). Utilize technology and resources (systems, telephones ... Diploma, Associates Degree or Bachelor's Degree program • Minimum of 3 years of nursing ...

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Utilization Management Associate information

What does a utilization management associate do?

A Utilization Management Associate is responsible for reviewing healthcare services and determining whether they are medically necessary, appropriate, and efficient. They work with healthcare providers, insurance companies, and patients to ensure that treatments comply with established guidelines and policies. Their role often includes reviewing medical records, processing authorizations, and assisting in the coordination of care to optimize the use of healthcare resources. This position helps control costs while ensuring that patients receive the appropriate level of care.

What skills and qualifications are needed to thrive as a utilization management associate?

A Utilization Management Associate typically needs a background in healthcare administration or a related field, strong analytical skills, and knowledge of medical terminology and insurance guidelines. Familiarity with utilization review software, electronic health records (EHRs), and regulatory compliance systems is important, and certifications like Certified Professional in Healthcare Management (CPHM) can be advantageous. Attention to detail, effective communication, and strong organizational skills help associates excel in evaluating medical necessity and collaborating with care teams. These competencies ensure accurate, efficient review processes that support quality patient care and compliance with payer requirements.

What are the typical daily responsibilities of a utilization management associate?

Utilization Management Associates typically review medical records, verify insurance coverage, and coordinate with healthcare providers to ensure that treatments and services meet established guidelines and payer requirements. They also communicate with physicians and patients to gather necessary information for authorization requests. By ensuring appropriate utilization of healthcare resources, they help support patient care while managing costs and compliance for their organization. Collaboration with clinical staff and insurance representatives is a key part of the role, contributing to effective case management.

What is the difference between Utilization Management Associate vs Utilization Review Coordinator?

AspectUtilization Management AssociateUtilization Review Coordinator
CertificationsTypically requires a healthcare-related certification or licenseOften requires similar certifications, such as CCM or RHIA
Work EnvironmentWorks in insurance companies, healthcare providers, or managed care organizationsWorks in hospitals, insurance companies, or healthcare facilities
Job FocusAssists in reviewing medical necessity and authorization processesCoordinates and conducts utilization reviews and approvals
Common UsageUsed interchangeably in healthcare and insurance settingsOften used in hospital and insurance contexts

The Utilization Management Associate and Utilization Review Coordinator roles share similarities in certifications and work environments, focusing on reviewing medical necessity and authorization. The main difference lies in their specific responsibilities, with associates assisting in the process and coordinators actively conducting reviews and approvals.

What cities near Hialeah, FL are hiring for Utilization Management Associate jobs?

Cities near Hialeah, FL with the most Utilization Management Associate job openings:

Infographic showing various Utilization Management Associate job openings in Hialeah, FL as of August 2026, with employment types broken down into 1% As Needed, 84% Full Time, 13% Part Time, and 2% Contract. Highlights an 82% Physical, 3% Hybrid, and 15% Remote job distribution.

Medical Director - Individual Segment

Miami, FL • On-site

Elevance Health
Health Care and Social Assistance • 10K+ employees
Learn more about Elevance Healthexternal

Other

Posted 4 days ago

Elevance Health rating

7.5

Company rating: 7.5 out of 10

Based on 358 frontline employees who took The Breakroom Quiz

Job description

Medical Director - Individual Segment

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Alternate locations may be considered.

The Medical Director will have program management responsibilities including clinical policy development, program development/implementation, and overseeing clinical/non-clinical activities. Will also be responsible for utilization review/management. The role focuses on reviewing cases for medical necessity, making benefit determinations, evaluating in-network and out-of-network care requests, and supporting utilization management functions. Team members may also contribute to process improvement and cost-of-care initiatives, although participation in these projects is optional.

How you will make an impact:

  • Supports clinicians to ensure timely and consistent responses to members and providers.
  • Provides guidance for clinical operational aspects of a program.
  • Conducts peer-to-peer clinical reviews with attending physicians or other providers to discuss review determinations, and patients' office visits with providers and external physicians.
  • May conduct peer-to-peer clinical appeal case reviews with attending physicians or other ordering providers to discuss review determinations.
  • Serves as a resource and consultant to other areas of the company.
  • May be required to represent the company to external entities and/or serve on internal and/or external committees.
  • May chair company committees.
  • Interprets medical policies and clinical guidelines.
  • May develop and propose new medical policies based on changes in healthcare.
  • Leads, develops, directs, and implements clinical and non-clinical activities that impact health care quality cost and outcomes.
  • Identifies and develops opportunities for innovation to increase effectiveness and quality.

Minimum Requirements:

  • Requires MD or DO and Board certification approved by one of the following certifying boards is required, where applicable to duties being performed, American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA).
  • Must possess an active unrestricted medical license to practice medicine or a health profession.
  • Unless expressly allowed by state or federal law, or regulation, must be located in a state or territory of the United States when conducting utilization review or an appeals consideration and cannot be located on a US military base, vessel or any embassy located in or outside of the US.
  • Minimum of 10 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
  • For Health Solutions and Carelon organizations (including behavioral health) only, minimum of 5 years of experience providing health care is required.
  • Additional experience may be required by State contracts or regulations if the Medical Director is filing a role required by a State agency.

Preferred Qualifications:

  • Experience in managed care experience strongly preferred.
  • 1-2 years utilization management review experience preferred.
  • Clinical experience working in internal medicine or family practice strongly preferred.

Job Level: Director Equivalent

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Physician/Doctor/Dentist

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About Elevance Health

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Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Indianapolis, IN, US

Year founded

2004

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