Utilization Review Nurse

Description • Miami Jewish Health is one of the largest providers of healthcare and living options for aging adults in the Southeast. We operate Florida PACE (Program of All-Inclusive Care for the Elderly) Centers, the largest PACE program in Florida, which serves as health plan, healthcare provider, and social center designed for older adults with complex medical needs. We have four adult day health centers that serve participants in Miami-Dade and Broward counties. The following Job Description will also apply at Broward Pace Program sites. Job Summary The Utilization Nurse is responsible for conducting prospective, concurrent, and retrospective clinical reviews to determine medical necessity, level of care, and appropriateness of services across the continuum. This role collaborates closely with hospital UR/Case Management, facility and community providers, and the Interdisciplinary Team (IDT) to facilitate timely care transitions, prevent avoidable days, and ensure members receive only medically necessary services in accordance with evidence-based criteria, payer policies, and regulatory requirements. The Utilization Nurse communicates authorization decisions and care progression, coordinates documentation exchange, and maintains comprehensive, audit-ready records. All utilization management activities are performed in accordance with CMS PACE regulations (42 CFR Part 460) and are intended to support-rather than replace-the clinical decision-making authority of the PACE Interdisciplinary Team (IDT). Essential Job Functions Utilization Review & Authorizations • Performs admission, continued stay, and discharge reviews for inpatient, observation, post-acute (SNF, IRF, LTACH), home health, DME, and outpatient services. • Applies evidence-based criteria (e.g., InterQual/MCG) and health plan policies to determine medical necessity and level of care; document detailed clinical rationales supporting approvals or non-authorizations. • Issues and communicates authorization decisions within required turnaround times; escalates complex cases to a Medical Director per policy. • Identifies avoidable days and collaborates with providers to resolve barriers to progression of care and discharge. • Travels to different acute care hospitals in the area to meet case managers and hospitalist to plan participant discharge in a timely and organized manner. Concurrent Review & Care Progression • Conducts timely concurrent reviews with hospitals and facilities to assess clinical stability, treatment response, and discharge readiness. • Reviews clinical progress and diagnostic information to align services with the least restrictive, most appropriate level of care. • Coordinates peer-to-peer discussions between providers and the Medical Director as needed. Collaboration with Hospitals, Providers, and IDT • Serves as the payer-side clinical liaison to hospital UR/CM, physician offices, post-acute providers, and community services. • Provides the IDT with routine updates on authorization status, level-of-care determinations, expected discharge plans, surface risks (e.g., readmission, SDoH barriers) and collaborates on mitigation strategies. • Ensures the timely exchange of clinical records supporting determinations, upload, index, and route documentation to the IDT and relevant providers. • Coordinates participant/patient discharge in conjunction with the Social Work team and other relevant modalities, in a timely and organized manner to their next level of care organization. Documentation, Compliance & Communication • Maintains complete, accurate, and audit-ready documentation of all utilization review activities in the UM platform; capture timestamped contacts and rationale. • Adheres to CMS, state Medicaid, Medicare Advantage, NCQA/URAC, and internal policy requirements, including timely notifications and member/provider communications. • Generates adverse determination letters, notices of non-coverage, and appeal summaries that clearly outline medical necessity rationale and criteria used. • Ensures all adverse determinations include participants' rights and appeal processes. Member & Provider Experience • Communicates determinations with clarity, professionalism, empathy and provides education on criteria and required clinicals. • Partners with providers to prevent denials by clarifying documentation needs and aligning on care progression and discharge planning. • Supports appeals and grievances with organized, evidence-based clinical summaries. Quality Improvement & Performance • Tracks and helps improve key outcomes, such as avoidable days, readmission risk, LOS variance, denial overturn rates, and provider satisfaction. • Participates in case rounds, inter-rater reliability reviews, and continuous improvement initiatives. Technology & Tools • Navigates electronic medical records (EMRs), UM platforms, eligibility/benefits systems, and secures messaging tools to obtain and share clinical documentation. • Uses standard office tools (e.g., Outlook, Excel, Word) to organize caseloads, track follow-ups, and report performance. Job Requirements Education • Graduate from an accredited Nursing program. Licenses/Certifications • Current RN or LPN license by the Florida State Board of Nursing. • CCM, CPUR, CPHQ, ACM-RN, or equivalent preferred. Experience • 2-4 years of experience in healthcare administration, utilization management, or a related operational role. • 2+ years of recent clinical experience in acute care, post-acute, emergency/observation, or related settings with strong assessment skills. • Prior Utilization Management/Review or Managed Care experience (payer, IPA, ACO, or delegated UM). Abilities Required • Clinical judgment and evidence-based decision-making. • Strong negotiation and collaborative problem-solving skills when working with providers. • High attention to detail and ability to produce audit-ready documentation. • Effective time management, prioritization, and adherence to turnaround times (TAT). • Professional, clear, and empathetic verbal and written communication skills. • Strict adherence to HIPAA, as well as all company privacy and security policies. • Ability to maintain the confidentiality of member information. • Ability to complete all required compliance trainings and participate in internal and external audits. • Demonstrated ability to interpret clinical documentation and synthesize information to make evidence-based medical necessity determinations. • Ability to sit for extended periods and manage prolonged screen time. • Ability to travel when needed for trainings, meetings, or audits. • Ability to meet coverage needs (evenings/weekends/holidays as required by census and regulatory timelines). • Ability to collaborate effectively with hospital UR/CM and multidisciplinary teams in a fast-paced environment. • Proficiency with EMR records, UM systems, and Microsoft Office (Word, Excel, Outlook). • Knowledge of ICD-10, CPT/HCPCS, DRGs, and documentation requirements that support medical necessity. • Familiarity with InterQual/MCG criteria, coverage policies, and Medicare Advantage/Medicaid requirements. Functional Demands Environment Work Conditions • Remote role with reliable high-speed internet. Infectious Material Exposure • None Organizational Expectations • Ensures that resident's/patient's rights are adhered to • Demonstrates professionalism and accountability • Demonstrates a caring attitude consistent with Miami Jewish EmpathicareSM toward MJH residents, patients, family members, employees, and other facility guests • Demonstrates excellent communication skills • Ensures confidentiality and security of patients' medical information • Identifies and utilizes appropriate channels of communication • Able to speak, read and write English • Able to think and act calmly to meet unusual occurrences of the job • Adheres to the organization's Mission, Vision and Values • Participates in departmental activities, meetings and in-services and follows established guidelines • Maintains a safe working environment The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed. We believe in the power of empathy, the value of relationships and the importance of a life well-lived. Come see why Miami Jewish Health is unlike anywhere you've ever worked before. We offer competitive compensation, medical/dental/vision coverage and a 403(b)-retirement savings plan for eligible full and part-time positions, free on-campus parking, an onsite fitness center and more. Miami Jewish Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training. Miami Jewish Health and FL PACE Centers conducts a Level II background check as part of the onboarding process for all new hires. The following link contains information and resources pertaining to the AHCA Level II background conducted at Miami Jewish Health and FL PACE Centers. FL Clearinghouse | Florida Agency for Health Care Administration

Created: 2026-03-04