Senior Registered Nurse

📍 Location & Practice Overview

• Base location: Miami, FL
• Department: Utilization Management
• Practice type: Health Plan Utilization Review
• Care setting: Inpatient, Outpatient & Post-Acute
• Patient population: Managed care members across various acuity levels

📋 Utilization Management Responsibilities

• Perform medical necessity reviews for inpatient and outpatient elective procedures using KFHP policies, Milliman, and InterQual guidelines
• Review and authorize inpatient hospital stays, rehabilitation services, skilled nursing admissions, home care, and infusion services
• Facilitate discharge planning requests and coordinate with providers in real-time
• Verify member eligibility and document all authorization activities in the system
• Refer cases to Medical Director when criteria are not met and prepare denial notifications
• Communicate directly with referring providers to obtain additional clinical information when needed

✅ Requirements

⏱ Schedule & Work Environment

• Schedule: Standard business hours with real-time provider collaboration
• Setting: Utilization management supporting inpatient, outpatient, and post-acute care
• Documentation: Real-time entry into utilization management platform
• Team: Work with Medical Directors and interdisciplinary care teams

👥 About Integrated Resources, Inc

Integrated Resources, Inc (IRI) is a national staffing firm founded in 1996 that specializes in placing experienced healthcare professionals into contract, contract-to-hire, and permanent roles. With a strong focus on nursing and clinical research, IRI partners with health plans, hospitals, and health systems across the country to deliver qualified talent for specialized positions like utilization management.

• Healthcare specialties: Utilization Management, Case Management, Clinical Research
• Focus: Connecting experienced clinicians with quality opportunities
• Accreditation: Joint Commission certified for healthcare staffing services

🏥 Clinical Focus & Case Mix

• Reviews cover inpatient admissions, elective surgeries, rehabilitation, skilled nursing, and home infusion services
• Support appropriate level of care determinations for managed care members
• Emphasis on timely discharge planning and transition of care coordination
• Collaboration with specialty physicians and non-participating providers when needed

🖥 Systems & Documentation Standards

• Utilization management platform with real-time documentation requirements
• Access to medical necessity guidelines (Milliman, InterQual)
• Standard office technology suite for communication and reporting
• Emphasis on accurate, timely documentation of all review activities

📊 Quality & Compliance Focus

• Adherence to KFHP policies, Process Standards, and Standard Operating Procedures
• Consistent application of medical health benefit policies
• Timely verbal and written notification processes for authorizations and denials
• Support regulatory and accreditation requirements through thorough documentation

🌆 Living and Working in Miami, FL

Miami offers a dynamic environment for healthcare professionals with its diverse patient populations, vibrant communities, and year-round warm climate. The area features strong demand for utilization management expertise as local health systems manage complex care needs across a multicultural region. Easy access to major transportation corridors and a mix of urban and coastal living options make it an attractive location for experienced nurses seeking new professional challenges.

• Healthcare demand: High volume of managed care activity
• Housing options: Diverse neighborhoods from urban to waterfront
• Transportation access: Major international airport and public transit
• Recreation opportunities: Beaches, cultural venues, and outdoor activities

❓ FAQ

🔗 Senior Registered Nurse – Utilization Management – Miami, FL

This Senior Registered Nurse position in Miami supports a health plan’s utilization management program by conducting medical necessity reviews for inpatient and outpatient services. Working through Integrated Resources, Inc, the role focuses on prior authorizations, concurrent reviews, discharge planning coordination, and appropriate application of clinical guidelines. Experienced nurses with critical care backgrounds and utilization review knowledge will find this a strong opportunity to apply clinical judgment in a structured, collaborative environment that emphasizes timely decisions and provider communication. The position offers the chance to contribute to efficient care delivery while maintaining compliance with established health plan policies and national criteria sets.

🚀 Apply for This Position

Complete application for Senior Registered Nurse at Integrated Resources, Inc.