Behavioral Health Utilization Review Nurse

Job Description

Job Description

Actalent is hiring a Utilization Management Nurse! Job Description

The Utilization Management Nurse (UMN) plays a crucial role in reviewing service authorization requests to ensure appropriate service utilization. Working under the general supervision of the Director and / or Manager / Supervisor of Medical Management, and in collaboration with an interdisciplinary team, the UMN manages complex cases and contributes to internal process development. This role involves close interaction with Medical Directors and other Medical Management staff to direct utilization and capture data effectively.

Responsibilities

• Review prior authorization requests for medical necessity and appropriateness, utilizing standardized Review Criteria.
• Coordinate with the Medical Director / Physicians for requests outside standard Review Criteria.
• Maintain compliance with federal, state guidelines, and contractual requirements.
• Obtain necessary documentation, ensuring completion of assigned caseload by addressing discrepancies.
• Serve as a liaison between the Medical Director, physicians, and office staff, resolving prior authorization issues.
• Communicate denial determinations to providers when necessary.
• Evaluate and monitor appropriate utilization of resources such as durable medical equipment, hospitalizations, and home healthcare.
• Provide current and timely documentation reflecting department work processes and policy guidelines.
• Promote safe and appropriate coordination of care and optimal utilization of resources.
• Identify and participate in the development of programs, policies, and procedures for continuous quality improvement.
• Assure adherence to company and department policies regarding confidentiality.
• Participate in regular departmental training.
• Serve as a plan liaison to coordinate enrollee benefits with providers and external organizations.
• Prepare and present reports on department activities as assigned.

Essential Skills

Additional Skills & Qualifications

Work Environment

The role offers a hybrid work schedule with in-office requirements in Sunrise on Tuesdays from 8 : 30 AM to 5 : 00 PM, including a 30-minute lunch break. Initial training will take 2-4 weeks, involving shadowing a team member on-site on Tuesdays and remote shadowing via Teams.

Pay and Benefits

The pay range for this position is $35.00 - $38.00 / hr.

Eligibility requirements apply to some benefits and may depend on your job

classification and length of employment. Benefits are subject to change and may be

subject to specific elections, plan, or program terms. If eligible, the benefits

available for this temporary role may include the following :

Workplace Type

This is a hybrid position in Sunrise,FL.

Application Deadline

This position is anticipated to close on Jul 3, 2025.

About Actalent

Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email [email protected] for other accommodation options.