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Utilization Review Rn Jobs in Miami, FL (NOW HIRING)

Sanitas

Case Management RN (68014)

Doral, FL · On-site

... RN manages the transition of care for members post-discharge and those with chronic conditions ... coordination, utilization review, or population health management within a healthcare setting.

Sanitas

Case Management RN (68014)

Doral, FL · On-site

... RN manages the transition of care for members post-discharge and those with chronic conditions ... coordination, utilization review, or population health management within a healthcare setting.

Community Medical Group

APRN

Miami, FL · On-site

$106K - $145K/yr

As an APRN, you will play a vital role in delivering high-quality, comprehensive care to our ... Support utilization review and billing documentation processes * Provide clinical guidance and ...

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Utilization Review Rn information

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How much do utilization review rn jobs pay per hour?

As of Aug 16, 2026, the average hourly pay for utilization review rn in Miami, FL is $40.44, according to ZipRecruiter salary data. Most workers in this role earn between $31.97 and $46.44 per hour, depending on experience, location, and employer.

What is a utilization review RN?

A Utilization Review RN is a registered nurse who evaluates the necessity, appropriateness, and efficiency of healthcare services and treatments provided to patients. They review medical records, collaborate with healthcare teams, and ensure that patient care meets established guidelines and payer requirements. Their role helps control costs, optimize care, and support compliance with healthcare regulations. Utilization Review RNs often work in hospitals, insurance companies, or managed care organizations.

How does a utilization review RN collaborate with physicians and other healthcare professionals during the patient care review process?

A Utilization Review RN works closely with physicians, case managers, and other healthcare team members to ensure that patients receive appropriate care while adhering to regulatory and insurance guidelines. This collaboration often involves discussing clinical findings, clarifying documentation, and negotiating care plans to meet both patient needs and payer requirements. Effective communication and teamwork are essential, as Utilization Review RNs frequently serve as liaisons between clinical staff and insurance representatives to facilitate timely authorizations and prevent unnecessary delays in patient care.

What are the key skills and qualifications needed to thrive as a utilization review RN, and why are they important?

To thrive as a Utilization Review RN, you need a current RN license, strong clinical assessment skills, and knowledge of healthcare regulations and insurance guidelines. Familiarity with utilization management software, electronic health records (EHRs), and relevant certifications like CCM or ACM is often required. Excellent critical thinking, communication, and negotiation skills help you advocate for appropriate patient care while collaborating with providers and payers. These skills ensure cost-effective, quality care and compliance with regulatory standards in healthcare delivery.

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

AspectUtilization Review RnCase Manager
CredentialsRN license, certifications in utilization reviewRN license, certifications in case management
Work EnvironmentHospitals, insurance companies, healthcare facilitiesHospitals, community agencies, insurance companies
Primary FocusReviewing medical necessity and appropriateness of careCoordinating patient care and discharge planning

Utilization Review Rns primarily focus on evaluating the necessity of medical treatments, while Case Managers coordinate patient care and discharge planning. Both roles require RN licensure and certifications, but their daily responsibilities and work environments differ slightly, with Utilization Review Rns concentrating on review processes and Case Managers on patient advocacy and care coordination.

How to get into utilization review as a registered nurse?

To become a utilization review RN, you typically need a valid registered nurse license and experience in clinical settings. Additional certifications such as the Certified Professional in Healthcare Quality (CPHQ) or knowledge of medical coding and insurance processes can enhance your qualifications. Gaining experience in case management or health insurance companies can also improve your chances of entering the field.

What are the most commonly searched types of Utilization Review Rn jobs in Miami, FL?

The most popular types of Utilization Review Rn jobs in Miami, FL are:

What are popular job titles related to Utilization Review Rn jobs in Miami, FL?

For Utilization Review Rn jobs in Miami, FL, the most frequently searched job titles are:

What job categories do people searching Utilization Review Rn jobs in Miami, FL look for?

The top searched job categories for Utilization Review Rn jobs in Miami, FL are:

What cities near Miami, FL are hiring for Utilization Review Rn jobs?

Cities near Miami, FL with the most Utilization Review Rn job openings:

Utilization Review Rn jobs near you
Infographic showing various Utilization Review Rn job openings in Miami, FL as of August 2026, with employment types broken down into 71% Full Time, and 29% Part Time. Highlights an 72% In-person, 14% Hybrid, and 14% Remote job distribution, with an average salary of $84,116 per year, or $40.4 per hour.

Senior Registered Nurse

Integrated Resources INC

Miami, FL

Full-time

Re-posted 2 days ago

Job description

Company Description

Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-states most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing.

Job Description
  • Responsible for completing medical necessity reviews using KFHP policies and procedures, reviewing inpatient and outpatient elective procedures requiring prior authorization, inpatient hospital stays, and requesting, assessing and appropriately channeling/facilitating discharge planning requests Consistently applies medical health benefit policy and medical management guidelines to authorize services. Identifies and refers requests for services to the appropriate Medical Director when guidelines are not met.
  • Receives requests for authorization of services, including inpatient hospital admissions, inpatient rehabilitation services, Skilled Nursing admission), home care home infusion services, outpatient and/or inpatient elective surgery, and referrals for specialty physician consultation with non-participating physician offices. Documents date that the request was received, nature of request, utilization determination (and events leading up to the determination).
  • Verifies and documents member eligibility for services.
  • Communicates and interacts in a real time bases via "live" encounters with providers and appropriate others to facilitate and coordinate the activities of the Utilization Management process(es).
  • Utilize technology and resources (systems, telephones, etc.) to appropriately support work activities. Voice mail as an adjunct to the daily work activities versus major reliance for giving and receiving information from providers; Accessing and applying Medical Guidelines for decision making prior to Medical Director/Physician Advisor referral.
  • Applies submitted information to KFHP authorization process (utilizing Milliman, USA, Interqual medical guidelines, Process Standards, Policies and Procedures, and Standard Operating Procedures). Authorizes services in accordance with medical and health benefits guidelines.
  • Coordinates with the referral source if insufficient information is not available to complete the authorization process. Advises the referral source and requests specific information necessary to complete the process. Documents the request and follows KFHP process for requesting additional information.
  • Refers cases to KFHP Medical Director for medical necessity review when medical information provided does not support the nurse review process for giving an approval of services requested.
  • Documents case activities for Utilization determinations and discharge planning in MeDecision in a real time manner (as events occur). Completes detail line as indicated. Completes ASF per policy.
  • Provides verbal/fax denial notification to the requesting provider as per policy. Generates denial letter in a timely manner.
  • Adheres to Process Standards, Standard Operating Procedures, and Policies and Procedures, as defined by specific UM role (Prior Authorization, Concurrent Review)
Qualifications

Current FL RN licensure

Registered Nurse graduated from an accredited Diploma, Associates Degree or Bachelor's Degree program

Minimum of 3 years of nursing experience, in related clinical setting, preferably critical care (e.g. ER, ICU)

Experience with Utilization Review and/or Prior Authorization

Familiar with Interqual Criterion

Knowledge of MS Office including Word, Excel, and Outlook

Additional Information

Riya Khem

Life Science Recruiter 

Integrated Resources, Inc.




Integrated Resources logo

About Integrated Resources

Sourced by ZipRecruiter

Integrated Resources Inc (IRI), based in Edison, NJ, US, is an esteemed player in the staffing solutions industry with a credible presence on their official website irionline.com. Notably, IRI provides a range of professional staffing services including contract, contract-to-hire, and direct hire solutions to a wide spectrum of industries such as healthcare, life sciences, manufacturing, financial, insurance, and others. Since its inception, IRI has been committed to delivering top-talent and optimum solutions to meet its clients' diverse needs.

Industry

Recruiting and staffing services

Company size

51 - 200 Employees

Headquarters location

Edison, NJ, US

Year founded

1996

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