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Utilization Management Case Manager Rn Jobs in Florida

UF Health

Manager, Utilization Review

Gainesville, FL · On-site

Overview The Manager of Utilization Review provides operational leadership and oversight for ... Accredited Case Manager - Registered Nurse (ACM-RN) preferred. * Certified Case Manager (CCM ...

TotalMed RN

Travel RN Case Management

Largo, FL · On-site

TotalMed RN is seeking a travel nurse RN Case Manager, Acute Care Case Management for a travel nursing job in Largo, Florida. & Requirements * Specialty: Acute Care Case Management * Discipline: RN * ...

TotalMed RN

Travel Case Management RN

Brooksville, FL · On-site

As a RN Case Manager, you'll work with a highly skilled team of professionals to advocate for patients, evaluate, plan, provide resources and facilitate communication with family members. You will be ...

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Utilization Management Case Manager Rn information

What is the difference between Utilization Management Case Manager Rn vs Utilization Review Nurse?

AspectUtilization Management Case Manager RnUtilization Review Nurse
CredentialsRN license, certification in case management (e.g., CCM)RN license, often with certification in utilization review
Work EnvironmentInsurance companies, healthcare facilities, case management teamsHospitals, insurance companies, outpatient clinics
Primary FocusCoordinating patient care, managing cases, ensuring appropriate utilizationReviewing medical necessity, approving or denying services
Common TasksAssessing patient needs, developing care plans, liaising with providersEvaluating medical records, making utilization decisions, ensuring compliance

The main difference is that the Utilization Management Case Manager Rn focuses on coordinating patient care and managing cases, while the Utilization Review Nurse primarily reviews medical records to approve or deny services. Both roles require RN licensure and related certifications, but their daily responsibilities and work environments differ slightly.

Are utilization management case managers in demand?

Utilization management case managers are in demand due to the growing need for healthcare cost control and efficient patient care coordination. Employers in healthcare organizations, insurance companies, and managed care plans seek professionals with strong clinical knowledge, certification, and experience in utilization review processes. The role offers stable employment opportunities as healthcare systems focus on cost-effective treatment management.

What cities in Florida are hiring for Utilization Management Case Manager Rn jobs?

Cities in Florida with the most Utilization Management Case Manager Rn job openings:

Manager, Utilization Review

Gainesville, FL • On-site

Socket.dev
Network Security • 1 - 10 employees
Learn more about Socket.devexternal

Other

This job post has expired today. Applications are no longer accepted.

Job description

Overview

The Manager of Utilization Review provides operational leadership and oversight for utilization review activities across the health system. This role is responsible for ensuring clinical appropriateness of patient status determinations, regulatory compliance, medical necessity review processes, denial prevention strategies, and efficient utilization of healthcare resources. The Manager leads a team of Utilization Review Specialists, Nurses, and related staff while partnering closely with physician advisors, case management, care coordination, revenue cycle, compliance, and payer relations teams. The Manager establishes standardized utilization management processes across all facilities, drives performance improvement initiatives, supports regulatory compliance, and ensures accurate inpatient, observation, and outpatient status determinations to optimize reimbursement and reduce avoidable denials. This role aligns with enterprise strategies focused on quality outcomes, efficient resource utilization, and sustainable financial performance. The position supports organizational efforts related to utilization review plans, Condition Code 44 processes, MOON notifications, admission status accuracy, denial prevention, and compliance with CMS Conditions of Participation.

Qualifications
Education
  • Bachelor’s degree in nursing.
  • Master’s degree in nursing, Healthcare Administration, Business Administration, or related field preferred.
Experience
  • Minimum five (5) years of Utilization Management, Case Management, Revenue Cycle, or Denials Management experience.
  • Minimum three (3) years of leadership experience managing hospital UM operations.
  • Experience leading multi-site or enterprise-wide coding operations preferred.
  • Experience working with Medicare, Medicaid, and commercial payers.
  • Experience analyzing denial and authorization data.
  • Experience with complex health system or academic medical centers is strongly preferred.
  • Epic experience a must.
  • Knowledge of claims processing, denials management, and reimbursement analysis.
  • Ability to interpret regulatory requirements and translate them into operational processes.
  • Ability to manage multiple priorities and lead through organizational change.
License/Certification/Registration
  • Registered Nurse (RN) required.
  • Prior Authorization Certified Specialist (PACS) preferred.
  • Accredited Case Manager – Registered Nurse (ACM-RN) preferred.
  • Certified Case Manager (CCM) preferred.
  • Certified Professional in Healthcare Quality (CPHQ) preferred.
  • Certification in Healthcare Quality and Management (HCQM) preferred.
  • Certified Professional in Utilization Review (CPUR) preferred.
  • Clinical Medical Assistant Certification (CMAC) preferred.
  • Certified Revenue Cycle Representative (CRCR) preferred.
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