Florida Licensed Utilization Review Nurse

Job Summary

Reviewing payer denials and authoring appeal letters, the full-time Florida Licensed Utilization Review Nurse will focus on Medical Necessity denials while working remotely and collaborating with a Physician Advisor to ensure accurate and timely appeals.

Key responsibilities

• Evaluate medical necessity denials against payer policies and clinical guidelines to determine appeal eligibility
• Author clear and persuasive medical necessity appeal letters based on clinical documentation and payer criteria
• Track denial reasons and outcomes to identify patterns and recommend process improvements

Required qualifications

• Registered Nurse (RN) with at least 3 years of acute care hospital experience
• Minimum of 3 years of utilization review/utilization management experience
• Prior experience authoring medical necessity appeal letters
• Strong understanding of medical necessity criteria and payer policy
• Experience with InterQual and/or MCG criteria is preferred