Utilization Management Specialist (NE)

About the role

The Utilization Management Specialist supports the Indian River Hospital by reviewing admissions, concurrent care, and retrospective charts to ensure clinical performance and appropriate reimbursement. This PRN position works weekdays from 7:30 am to 4:30 pm and offers the chance to develop supervisory skills.

Key responsibilities

• Perform admission, concurrent, and retrospective reviews to assess medical necessity and impact on denial rates.
• Apply clinical judgment and predetermined criteria to identify problems, recommend corrective actions, and document findings.
• Achieve a minimum 85% IRR quarterly and complete 25‑30 reviews per day.
• Recommend appropriate treatment plans, discharge safety, and resource utilization.

Required profile

• Graduate of an accredited nursing program (Diploma, ADN, or BSN) with current RN licensure.
• Basic Life Support (BLS) certification.
• At least three years of full‑time clinical nursing experience.
• Strong analytical ability to gather data, assess conformity, and resolve issues.

Required skills

• Proficiency with Microsoft Office.
• Knowledge of medical terminology, anatomy, physiology, and basic disease processes.
• Familiarity with medical record coding standards and billing practices.
• Experience with Care Guidelines, Medical Necessity Criteria, and other UM criteria sets.