Utilization Review Nurse – PRN, Day Shift

This is a fully remote position, open to applicants in Florida.

📋 Description

• Perform reviews of hospital admissions to assess medical necessity and appropriate patient status.

• Conduct continued stay assessments utilizing approved clinical criteria and guidelines.

• Assess clinical documentation for accuracy, completeness, and adherence to payer and regulatory standards.

• Implement evidence-based criteria such as InterQual® and/or MCG®.

• Share review findings and recommendations with physicians, case management personnel, and leadership.

• Collaborate with Physician Advisors on complex cases or those not supported by established criteria.

• Aid in denial prevention efforts and ensure precise documentation.

• Fulfill additional duties as assigned.

• Work in partnership with physicians, case managers, revenue cycle teams, and interdisciplinary care groups to ensure proper patient status determinations and enhance reimbursement while supporting quality patient care.

⛳️ Requirements

• Graduate from an accredited nursing program.

• Hold a current and unrestricted Registered Nurse (RN) license.

• Have a minimum of five (5) years of acute care nursing experience in a hospital environment.

• Possess at least two (2) years of recent experience in hospital-based or health plan utilization review.

• Familiarity with acute admission and continued stay reviews.

• Proficient in various Electronic Health Records and case management systems.

• Excellent communication skills; able to convey information clearly and concisely, both verbally and in writing.

• Capability to excel in a fast-paced setting and adapt to frequently changing business demands.

• Ability to work autonomously with minimal supervision.

• PRN position requiring a minimum of forty (40) hours per month when hours are accessible.

• At least sixteen (16) of the required monthly hours must be completed during weekend shifts.

• Flexibility to work four- or eight-hour shifts between 7 a.m. and 7 p.m.

• Availability must be communicated thirty (30) days in advance.

• Required to work two of six recognized holidays each calendar year.

• Must maintain flexibility and communicate availability according to departmental scheduling requirements.

• Adhere to attendance and call-off policies.

• Capability to engage in physical activities, including lifting up to 25 pounds.

• Preferred certifications include Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), or Case Management Board Certification (CMGT-BC).

🏝️ Benefits

• Flexibility in PRN scheduling with the possibility of additional hours based on departmental requirements and employee availability.