Utilization Management Nurse

About the role

The Utilization Management Nurse supports the coordination, documentation, and communication of medical services and benefit determinations. Working independently, the nurse interprets clinical criteria, policies, and procedures to ensure members receive appropriate care.

Key responsibilities

• Interpret utilization criteria, policies, and procedures to make clinical determinations.
• Coordinate and communicate with providers, members, and internal teams to facilitate optimal care.
• Document and track benefit administration decisions.
• Apply MCG guidelines and evaluate requests for durable medical equipment.
• Support case management for Long‑Term Services and Supports (LTSS) members.

Required profile

• Licensed Registered Nurse (RN) with at least 3 years of acute, skilled, long‑term care or rehabilitation experience, OR Licensed Practical Nurse (LPN) with at least 5 years of similar experience.
• Current Florida nursing license with no disciplinary action.
• Residency in the state of Florida.
• Ability to work independently under general instructions and as part of a team.

Required skills

• Knowledge of MCG utilization guidelines.
• Experience evaluating durable medical equipment requests.
• Familiarity with health plan operations and prior authorization processes.
• Case management experience for LTSS members.

What we offer

• Full‑time 8‑hour shift (8:30 AM‑5:30 PM) Monday‑Friday.
• Opportunities to apply clinical expertise in a supportive, community‑focused environment.