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Utilization Management Nurse Jobs in Florida (NOW HIRING)

UF Health

RN, Utilization Management

Saint Johns, FL · On-site

Registered Nurse (RN) license with 3+ years experience in utilization review or case management Necessary Skills • Knowledge of healthcare utilization guidelines and compliance • Experience ...

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UF Health

RN, Utilization Management

Saint Johns, FL · On-site

Registered Nurse (RN) license with 3+ years experience in utilization review or case management Necessary Skills • Knowledge of healthcare utilization guidelines and compliance • Experience ...

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Utilization Management Nurse information

See Florida salary details

$29.1K

$66.9K

$121.8K

How much do utilization management nurse jobs pay per year?

As of Sep 5, 2026, the average yearly pay for utilization management nurse in Florida is $66,870.00, according to ZipRecruiter salary data. Most workers in this role earn between $48,200.00 and $78,100.00 per year, depending on experience, location, and employer.

What is a utilization management nurse?

A Utilization Management Nurse is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services provided to patients. They review medical records and treatment plans to ensure that care meets established guidelines and is cost-effective. Utilization Management Nurses work with healthcare providers, insurance companies, and patients to coordinate care and prevent unnecessary procedures or hospitalizations. Their goal is to support high-quality patient care while managing healthcare costs.

What does a utilization management nurse do?

A utilization management nurse ensures that healthcare services are administered appropriately. Their job responsibilities include working in a hospital, health practice, or other clinical setting reviewing patient clinical records, drafting clinical appeals, and overseeing staff members. The qualifications for a utilization management nurse include a nursing degree and a registered nursing license. Most people in this job also have career experience in case management and utilization review.

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

To thrive as a Utilization Management Nurse, you need a registered nursing license, strong clinical judgment, and experience in case management or utilization review. Familiarity with medical management software, InterQual or Milliman guidelines, and insurance authorization processes is typically required. Excellent analytical thinking, communication, and negotiation skills help you coordinate with providers and advocate for patients. These competencies ensure appropriate resource use, compliance with regulations, and optimal patient outcomes.

What are some common challenges a utilization management nurse faces when coordinating care between providers and insurance companies?

A Utilization Management Nurse often navigates the challenge of balancing patient advocacy with insurance guidelines, ensuring that care recommendations meet both clinical standards and payer requirements. Communicating complex medical information to both providers and insurance representatives can be demanding, especially when there are disagreements about coverage or medical necessity. Additionally, staying updated on changing policies and maintaining thorough documentation under tight deadlines are frequent aspects of the role. Strong collaboration skills and attention to detail are essential for success in this position.

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

AspectUtilization Management NurseCase Manager
CredentialsRN license, certifications in utilization reviewRN license, case management certification often preferred
Work EnvironmentInsurance companies, healthcare organizations, utilization review departmentsHospitals, community health agencies, insurance companies
Primary FocusReviewing medical necessity and appropriateness of servicesCoordinating patient care and discharge planning

Utilization Management Nurses primarily focus on reviewing medical necessity and approving healthcare services, while Case Managers coordinate patient care and facilitate discharge planning. Both roles require RN licensure and work within healthcare or insurance settings, but their core responsibilities differ in scope and focus.

More about Utilization Management Nurse jobs

What are the most commonly searched types of Utilization Management Nurse jobs in Florida?

The most popular types of Utilization Management Nurse jobs in Florida are:

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

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

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

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

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Cities in Florida with the most Utilization Management Nurse job openings:

What are popular job titles related to Utilization Management Nurse jobs in FL?

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Utilization Management Nurse jobs near you
Infographic showing various Utilization Management Nurse job openings in Florida as of August 2026, with employment types broken down into 1% As Needed, 86% Full Time, 11% Part Time, and 2% Contract. Highlights an 88% Physical, 3% Hybrid, and 9% Remote job distribution, with an average salary of $66,870 per year, or $32.1 per hour.

Utilization Management Nurse - Case Management

Health First

Melbourne, FL • On-site

Full-time

Medical, Vision

Posted 28 days ago

Health First rating

7.1

Company rating: 7.1 out of 10

Based on 126 frontline employees who took The Breakroom Quiz

379th 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

Workplace

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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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