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Utilization Management Clinical Analyst Jobs in Florida

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Utilization Management Clinical Analyst information

What does a utilization management clinical analyst do?

A Utilization Management Clinical Analyst reviews and analyzes medical records, claims, and treatment plans to ensure that healthcare services provided to patients are medically necessary and cost-effective. They work with healthcare providers, insurance companies, and patients to evaluate the appropriateness of medical care based on established guidelines and policies. Their goal is to optimize patient outcomes while controlling healthcare costs and ensuring compliance with regulatory standards.

What are the key skills and qualifications needed to thrive as a utilization management clinical analyst?

To thrive as a Utilization Management Clinical Analyst, you need a solid background in healthcare, strong analytical abilities, and credentials such as RN or LPN licensure or relevant clinical certifications. Familiarity with utilization management software, electronic health records (EHRs), and claims processing systems is typically required. Excellent communication, critical thinking, and attention to detail are soft skills that help you collaborate effectively and make sound clinical determinations. These competencies are crucial for ensuring the appropriate use of medical resources, maximizing patient outcomes, and maintaining regulatory compliance.

How does a utilization management clinical analyst typically collaborate with clinical and administrative teams to ensure optimal patient care?

A Utilization Management Clinical Analyst works closely with both clinical staff, such as nurses and physicians, and administrative teams to review patient cases and ensure that treatments and services are medically necessary and align with payer guidelines. This role often involves participating in interdisciplinary meetings, communicating findings and recommendations, and helping to develop or refine care protocols. Effective collaboration is essential to balance quality patient care with cost efficiency, and analysts regularly provide feedback and support to improve clinical workflows and documentation.

What is the difference between Utilization Management Clinical Analyst vs Utilization Review Nurse?

AspectUtilization Management Clinical AnalystUtilization Review Nurse
CredentialsHealthcare degree, certifications like CCM or CUCRegistered Nurse (RN), state licensure, certifications like CCM
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, insurance companies, outpatient facilities
Employer & IndustryHealth insurance providers, managed care organizationsHospitals, insurance companies, healthcare facilities
Common Search & ComparisonUtilization Management Clinical Analyst vs Utilization Review Nurse

The main difference between a Utilization Management Clinical Analyst and a Utilization Review Nurse lies in their focus and credentials. Clinical Analysts often have healthcare degrees and certifications like CCM, working primarily in insurance or managed care settings. Utilization Review Nurses are registered nurses with licensure, working in hospitals or outpatient facilities. Both roles involve reviewing medical necessity, but their work environments and professional backgrounds differ.

What are popular job titles related to Utilization Management Clinical Analyst jobs in Florida?

For Utilization Management Clinical Analyst jobs in Florida, the most frequently searched job titles are:

What job categories do people searching Utilization Management Clinical Analyst jobs in Florida look for?

The top searched job categories for Utilization Management Clinical Analyst jobs in Florida are:

What cities in Florida are hiring for Utilization Management Clinical Analyst jobs?

Cities in Florida with the most Utilization Management Clinical Analyst job openings:

Utilization Management Clinical Analyst jobs near you
Infographic showing various Utilization Management Clinical Analyst job openings in Florida as of August 2026, with employment types broken down into 75% Full Time, and 25% Contract. Highlights an 100% In-person job distribution.

Utilization Management Nurse - Case Management

Health First

Melbourne, FL • On-site

Full-time

Medical, Vision

Posted 26 days ago

Health First rating

7.1

Company rating: 7.1 out of 10

Based on 126 frontline employees who took The Breakroom Quiz

380th of 898 rated healthcare providers

Job description

Job Requirements
POSITION SUMMARY
The Utilization Management (UM) Nurse performs medical necessity reviews on all payer admissions to determine appropriate admission status and documents all information that relates to insurance reimbursement in appropriate reviews for the Health First Integrated Delivery Network (IDN). The UM Nurse utilizes advanced clinical skills to facilitate the provision of care including the appropriate length of stay, patient status management, and resource utilization for all hospital admissions. The UM Nurse effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment and regularly collaborates with the Medical Staff, Physician Advisors, Case Managers, Revenue Cycle and other multi-disciplinary teams.
PRIMARY ACCOUNTABILITIES
  1. Evaluates admissions, continued stays, and services with evidence-based criteria (e.g., InterQual, MCG).
  2. Determines whether care is medically necessary, appropriate, and at the right level of care, and identifies over-utilization and under-utilization.
  3. Verifies compliance with Centers For Medicare and Medicaid Services (CMS) Conditions of Participation, Medicare and Medicaid rules, and Commercial payer requirements.
  4. Maintains accurate, defensible documentation, and supports audits and accreditation standards (e.g., Joint Commission, CMS).
  5. Reviews prior authorizations and concurrent approvals, initiating peer-to-peer reviews when criteria are not met, and manages denials, appeals, and retrospective reviews.
  6. Communicates decisions clearly to providers and stakeholders.
  7. Collaborates closely with licensed practitioners and advanced practice providers, case managers and social workers, coding, billing, and finance teams
  8. Advocates for patients while balancing payer requirements, and promotes efficient, timely progression of care.
  9. Supports appropriate resource utilization without compromising quality.
  10. Identifies opportunities for alternative levels of care (OBS vs IP, SNF, home health, etc.), early discharge planning, while contributing to organizational goals around quality metrics and cost containment.

Work Experience
MINIMUM QUALIFICATIONS
  • Education: Associate's degree in Nursing (ASN), or Nursing Diploma.
  • Work Experience: Five (5) years' experience in acute care (e.g., critical, intermediate, or emergency department) nursing environments.
  • Licensure: Registered Nurse (RN) licensure in the State of Florida, or endorsement.
  • Certification: American Heart Association Basic Life Support (AHA BLS) Healthcare Provider Completion Card prior to start date and maintained.
  • Skills/Knowledge/Abilities:
  1. Strong analytical, data management and computer skills.
  2. Ability to work autonomously and prioritize multiple tasks and role components.
  3. Ability to exercise sound judgment in interactions with physicians, payers, and
  4. other customers.
  5. Must be able to work remotely with adequate technology to support and
  6. maintain productivity.

PREFERRED QUALIFICATIONS
  • Education: BSN or Master's Degree in a healthcare field
  • Certification: Current Case Manager Certification (CCM or ACM)
  • Knowledge/Skills/Abilities: Current working knowledge of care transitions, utilization management, case management and managed care reimbursement

PHYSICAL REQUIREMENTS
  • Majority of time involves sitting or standing; occasional walking, bending, and stooping.
  • Long periods of computer time or at workstation.
  • Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
  • May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
  • Communicating with others to exchange information.
  • Visual acuity and hand-eye coordination to perform tasks.
  • Workspace may vary from open to confined.
  • May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

Benefits
ABOUT HEALTH FIRST
At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.
Schedule : Full-Time
Shift Times : 830am_500pm
Paygrade : PG-PG-39

What Health First employees say

Pay

Benefits

Hours and flexibility

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About Health First

Sourced by ZipRecruiter

Health First has been providing quality care to Brevard county residents for over 23 years. Health First delivers healthcare services throughout Brevard County with a network comprised of 4 hospitals with 868 beds, a health plan, and outpatient/wellness services including diagnostics, home health care, sleep centers, fitness facilities, pharmacy, cardiac rehabilitation, physical therapy, aging services, a hospice program, and bone/wellness center.

Industry

Health care and social assistance and medical equipment and supplies manufacturing

Company size

5,001 - 10,000 Employees

Headquarters location

Rockledge, FL, US

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