Florida Licensed Utilization Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse to ensure high-quality, medically necessary care for its members.

Key Responsibilities:

• Apply Milliman Care Guidelines (MCG) to assess medical necessity and appropriateness of treatments
• Review medical records and Good Faith Estimates to evaluate scheduled care and identify potential gaps
• Draft clear, member-facing letters outlining benefit decisions and collaborate with stakeholders to gather clinical information

Required Qualifications:

• Bachelor's degree
• Clinical credentials (RN)
• 5+ years of experience as a nurse providing direct patient care, preferably in a hospital setting
• 3+ years of utilization review experience, preferably in a health plan or managed care environment
• Hands-on experience using Milliman Care Guidelines (MCG)