Prior Authorization Nurse

Actalent • Sunrise, FL • 1d ago

Utilization Management Nurse!Job Description

The Utilization Management Nurse (UMN) plays a crucial role in reviewing service authorization requests to ensure appropriate service utilization. Working under the general supervision of the Director and/or Manager/Supervisor of Medical Management, and in collaboration with an interdisciplinary team, the UMN manages complex cases and contributes to internal process development. This role involves close interaction with Medical Directors and other Medical Management staff to direct utilization and capture data effectively.

Responsibilities

Review prior authorization requests for medical necessity and appropriateness, utilizing standardized Review Criteria.

Coordinate with the Medical Director/Physicians for requests outside standard Review Criteria.

Maintain compliance with federal, state guidelines, and contractual requirements.

Obtain necessary documentation, ensuring completion of assigned caseload by addressing discrepancies.

Serve as a liaison between the Medical Director, physicians, and office staff, resolving prior authorization issues.

Communicate denial determinations to providers when necessary.

Evaluate and monitor appropriate utilization of resources such as durable medical equipment, hospitalizations, and home healthcare.

Provide current and timely documentation reflecting department work processes and policy guidelines.

Promote safe and appropriate coordination of care and optimal utilization of resources.

Identify and participate in the development of programs, policies, and procedures for continuous quality improvement.

Assure adherence to company and department policies regarding confidentiality.

Participate in regular departmental training.

Serve as a plan liaison to coordinate enrollee benefits with providers and external organizations.

Prepare and present reports on department activities as assigned.

Essential Skills

Clinical review

Utilization review

Utilization management

Interqual

Milliman Commercial Guidelines

Medicaid

Medical management

Medicare

Managed care

Patient care

Medical record

Additional Skills & Qualifications

Current unrestricted Florida RN or LPN License.

Minimum of one year of utilization review experience and discharge planning in an acute care setting.

Four years of related clinical experience in a healthcare field or equivalent combination of education and experience.

Valid Florida Driver's License.

Knowledge of case management and utilization review concepts, including InterQual and Milliman Criteria, Florida Medicaid Program, and CMS Guidelines.

Knowledge of community and post-acute resources and related requirements.

Proficiency in word processing software, spreadsheet software such as Microsoft Excel, and electronic medical record software.

Work Environment

The role offers a hybrid work schedule with in-office requirements in Sunrise on Tuesdays from 8:30 AM to 5:00 PM, including a 30-minute lunch break. Initial training will take 2-4 weeks, involving shadowing a team member on-site on Tuesdays and remote shadowing via Teams.

Pay and Benefits

The pay range for this position is $35.00 - $38.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

Medical, dental & vision - Critical Illness, Accident, and Hospital - 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available - Life Insurance (Voluntary Life & AD&D for the employee and dependents) - Short and long-term disability - Health Spending Account (HSA) - Transportation benefits - Employee Assistance Program - Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a hybrid position in Sunrise,FL.

Application Deadline

This position is anticipated to close on Aug 29, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com (%20actalentaccommodation@actalentservices.com) for other accommodation options.

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