Utilization review nurse jobs in Miami Beach, FL - 210 jobs

Provides support for medical claim and internal appeals review activities - ensuring alignment with applicable state and federal regulatory requirements, Molina policies and procedures, and medically appropriate clinical guidelines. Contributes to overarching strategy to provide quality and cost-effective member care. ESSENTIAL JOB DUTIES: Facilitates clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases in which an appeal has been made, or is likely to be made, to ensure medical necessity and appropriate/accurate billing and claims processing. Reevaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of relevant and applicable state and federal regulatory requirements and guidelines, knowledge of Molina policies and procedures, and individual judgment and experience to assess the appropriateness of services provided, length of stay, level of care, and inpatient readmissions. Validates member medical records and claims submitted/correct coding, to ensure appropriate reimbursement to providers. Resolves escalated complaints regarding utilization management and long-term services and supports (LTSS) issues. Identifies and reports quality of care issues. Assists with complex claim review including diagnosis-related group (DRG) validation, itemized bill review, appropriate level of care, inpatient readmission, and any opportunities identified by the payment integrity analytical team; makes decisions and recommendations pertinent to clinical experience. Prepares and presents cases representing Molina, along with the chief medical officer (CMO), for administrative law judge pre-hearings, state insurance commissions, and judicial fair hearings. Reviews medically appropriate clinical guidelines and other appropriate criteria with medical directors on denial decisions. Supplies criteria supporting all recommendations for denial or modification of payment decisions. Serves as a clinical resource for utilization management, CMOs, physicians and member/provider inquiries/appeals. Provides training and support to clinical peers. Identifies and refers members with special needs to the appropriate Molina program per applicable policies/protocols. REQUIRED QUALIFICATIONS: At least 2 years clinical nursing experience, including at least 1 year of utilization review, medical claims review, long-term services and supports (LTSS), claims auditing, medical necessity review and/or coding experience, or equivalent combination of relevant education and experience. Registered Nurse (RN). License must be active and unrestricted in state of practice. Experience demonstrating knowledge of ICD-10, Current Procedural Technology (CPT) coding and Healthcare Common Procedure Coding (HCPC). Experience working within applicable state, federal, and third-party regulations. Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Common look proficiency. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. PREFERRED QUALIFICATIONS: Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM), Certified Professional in Healthcare Quality (CPHQ), or other health care certifications. Nursing experience in critical care, emergency medicine, medical/surgical or pediatrics. Billing and coding experience. To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V Pay Range: $29.05 - $67.97 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve. Newsweek Recognizes Sedgwick as America's Greatest Workplaces National Top Companies Certified as a Great Place to Work Fortune Best Workplaces in Financial Services & Insurance Utilization Review Coordinator **PRIMARY PURPOSE** : To assign utilization review requests; to verify and enter data in appropriate system(s); and to provide general support to clinical staff in a team environment. **ESSENTIAL FUNCTIONS and RESPONSIBILITIES** + Accesses, triages and assigns cases for utilization review (UR). + Responds to telephone inquiries proving accurate information and triage as necessary. + Enters demographics and UR information into claims or clinical management system; maintains data integrity. + Obtains all necessary information required for UR processing from internal and external sources per policies and procedures. + Distributes incoming and outgoing correspondence, faxes and mail; uploads review documents into paperless system as necessary. + Supports other units as needed. **ADDITIONAL FUNCTIONS and RESPONSIBILITIES** + Performs other duties as assigned. + Supports the organization's quality program(s). **QUALIFICATIONS** **Education & Licensing** High School diploma or GED required. **Experience** Two (2) years of administrative experience or equivalent combination of experience and education required. Customer service in medical field preferred. Workers compensation, disability and/or liability claims processing experience preferred. **Skills & Knowledge** + Knowledge of medical and insurance terminology + Knowledge of ICD9 and CPT coding + Excellent oral and written communication, including presentation skills + PC literate, including Microsoft Office products + Analytical and interpretive skills + Strong organizational skills + Detail Oriented + Good interpersonal skills + Ability to work in a team environment + Ability to meet or exceed Performance Competencies **WORK ENVIRONMENT** When applicable and appropriate, consideration will be given to reasonable accommodations. **Mental:** Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines **Physical:** Computer keyboarding, travel as required **Auditory/Visual:** Hearing, vision and talking The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time. Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. **If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.** **Sedgwick is the world's leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company's expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see** **sedgwick.com**

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time. As a Clinical Claim Review Nurse you will be responsible for the review and evaluation of clinical information and documentation. Reviews documentation and interprets data obtained from clinical records or systems and uses clinical decision making to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider claims. Independently coordinates the clinical resolution with clinician/MD support as required. Considers all documentation provided including medical records and system documentation to evaluate post-service claims for payment based on clinical policies, legislation, regulatory requirements, and plan benefits. Review requires navigation through multiple system applications as well as potential requirement to outreach to internal department or providers. Accurately applies review requirements to assure case is reviewed according to all company policies and procedures as well as state and federal laws and regulations. Adhere to company policies regarding confidentiality to protect member information. Required Qualifications5+ years of clinical experience required2+ years of experience as a Registered NurseMust have active, current and unrestricted RN licensure in state of residence1+ years of experience using Microsoft Office products, including Outlook and Excel, and previous experience using Internet Explorer and Google Chrome to effectively utilize review resources and conduct reviews. Preferred QualificationsManaged Care experience EducationAssociates Degree in Nursing required Bachelor of Science and Nursing preferred Anticipated Weekly Hours40Time TypeFull time Pay RangeThe typical pay range for this role is:$29. 10 - $62. 32This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan. No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit ************* cvshealth. com/us/en/benefits We anticipate the application window for this opening will close on: 02/02/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical, financial and resource utilization. Coordinates with healthcare Team for optimal efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention and coordination to decrease avoidable delays denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry, Facilitates communication between payers, review agencies and healthcare team, Identify delays in treatment or inappropriate utilization and serves as a resource, Coordinates communication with physicians, Identify opportunities for expedited appeals and collaborates resolve payer issues and ensures, maintains effective communication with Revenue Cycle Departments. Estimated pay range for this position is $45.00 / hour depending on shift as applicable. Degrees: * Associates. Licenses & Certifications: * Registered Nurse. Additional Qualifications: * RNs hired prior to 2/2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN; however, required to complete the BSN within 3 years of hire. * 3 years of hospital clinical experience preferred. * Excellent written, interpersonal communication and negotiation skills. * Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently. * Strong analytical, data management and computer skills. * Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. * Current working knowledge of payer and managed care reimbursement preferred. * Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families. * Knowledgeable in local, state, and federal legislation and regulations, and ability to tolerate high volume production standards. Minimum Required Experience: 3 Years of Utilization Review experience in an acute care setting required

(1) Full-Time Utilization Reviewer: Monday through Friday 8:30 a.m. - 5:00 p.m. Qualifications: Clinical Background with 2 years of UR experience RN (or) Master level Clinician CPI Certification required Experience in Psychiatric facility preferred Bilingual (English/Spanish) preferred 3-5 years' experience of Mental Health and Substance Abuse in an Inpatient setting. EQUAL OPPORTUNITY EMPLOYER Larkin Behavioral Health Services is an Equal Opportunity Employer committed to nondiscrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender status, marital status, age, disability, or covered veteran's status consistent with applicable federal and state laws.

Pool Utilization Review Registered Nurse, Case Management, Per Diem, Shift Varies (Rotating Weekends)-155669Baptist Health is the region's largest not-for-profit healthcare organization, with 12 hospitals, over 28,000 employees, 4,500 physicians and 200 outpatient centers, urgent care facilities and physician practices across Miami-Dade, Monroe, Broward and Palm Beach counties. With internationally renowned centers of excellence in cancer, cardiovascular care, orthopedics and sports medicine, and neurosciences, Baptist Health is supported by philanthropy and driven by its faith-based mission of medical excellence. For 25 years, we've been named one of Fortune's 100 Best Companies to Work For, and in the 2024-2025 U.S. News & World Report Best Hospital Rankings, Baptist Health was the most awarded healthcare system in South Florida, earning 45 high-performing honors.What truly sets us apart is our people. At Baptist Health, we create personal connections with our colleagues that go beyond the workplace, and we form meaningful relationships with patients and their families that extend beyond delivering care. Many of us have walked in our patients' shoes ourselves and that shared experience fuels out commitment to compassion and quality. Our culture is rooted in purpose, and every team member plays a part in making a positive impact - because when it comes to caring for people, we're all in. Description The purpose of this position is to conduct initial, concurrent, retrospective chart review for clinical, financial and resource utilization. Coordinates with healthcare Team for optimal efficient patient outcomes, while decreasing length of stay and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention and coordination to decrease avoidable delays denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry, Facilitates communication between payers, review agencies and healthcare team, Identify delays in treatment or inappropriate utilization and serves as a resource, Coordinates communication with physicians, Identify opportunities for expedited appeals and collaborates resolve payer issues and ensures, maintains effective communication with Revenue Cycle Departments. Estimated pay range for this position is $45.00 / hour depending on shift as applicable.Qualifications Degrees:Associates.Licenses & Certifications:Registered Nurse.Additional Qualifications:RNs hired prior to 2/2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN; however, required to complete the BSN within 3 years of hire.3 years of hospital clinical experience preferred.Excellent written, interpersonal communication and negotiation skills.Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently.Strong analytical, data management and computer skills.Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.Current working knowledge of payer and managed care reimbursement preferred.Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families.Knowledgeable in local, state, and federal legislation and regulations, and ability to tolerate high volume production standards.Minimum Required Experience: 3 Years of Utilization Review experience in an acute care setting required Job Case Management/Home HealthPrimary Location Boca RatonOrganization Boca Raton Regional HospitalSchedule Per DiemJob Posting Jan 7, 2026, 5:00:00 AMUnposting Date OngoingEOE, including disability/vets

Job Description The HOA Bookkeeper & Architectural Review Coordinator plays a key role in supporting the financial integrity, operational efficiency, and architectural standards of a luxury residential community. This position is responsible for day-to-day bookkeeping functions, overseeing architectural modification applications, assisting the General Manager with administrative and operational tasks, and supporting office staff in daily operations. The ideal candidate is detail-oriented, highly organized, customer-focused, and capable of multitasking in a fast-paced, high-expectation environment. Key Responsibilities: Maintain accurate financial records Process vendor invoices, reimbursements, and mics. expenses Assist with monthly financial reporting, reconciliations, and budget tracking Maintain organized financial records in compliance with Association policies Utilize strong Excel skills for reporting, tracking, and data management Manage architectural modification applications from submission through approval process Coordinate with the Architectural Review Committee (ARC) and management Creates monthly agenda for committee meetings Ensure applications comply with governing documents and community standards Communicate professionally with Subdivision property managers and or homeowners regarding application requirements and status Document findings and report any non-compliance to management and committee Assist the General Manager with administrative tasks, reporting, and special projects Support office staff with day-to-day operational needs Provide exceptional customer service to homeowners, Board members, vendors, and guests Maintain confidentiality and professionalism when handling sensitive information Coordinate appointments with vendors and property manager Full-time Mon-Fri 8:30am-5pm Salary: $60k - $65k DOE PLEASE DO NOT APPLY FOR THIS POSITION IF YOU LIVE MORE THAN 30 MINUTES FROM THE BOCA RATON AREA.

HealthCare Support Staffing, Inc. (HSS), is a proven industry-leading national healthcare recruiting and staffing firm. HSS has a proven history of placing talented healthcare professionals in clinical and non-clinical positions with some of the largest and most prestigious healthcare facilities including: Fortune 100 Health Plans, Mail Order Pharmacies, Medical Billing Centers, Hospitals, Laboratories, Surgery Centers, Private Practices, and many other healthcare facilities throughout the United States. HealthCare Support Staffing maintains strong relationships with top providers in healthcare and can assure healthcare professionals they will receive fast access to great career opportunities that best fit their expertise. Connect with one of our Professional Recruiting Consultants today to see how a conversation can turn into a long-lasting and rewarding career! Job Description Are you an experienced Registered Nurse with Utilization Review or Concurrent Review experience looking for a new opportunity with a prestigious Managed Care Company? Do you want the chance to advance your career by joining a rapidly growing company? If you answered “yes" to any of these questions - this is the position for you! Daily Responsibilities: Conducts pre-admission, concurrent and retrospective acute care, sub-acute, hospice, qualification of transitional care and long-term care needs for medical necessity Perform case reviews and complete all required documentation in appropriate database Collaborate with primary or attending physician, case managers, patient and/or family to provide continuity and quality of care in the most cost-effective manner. Timely completion of admission reviews (within 48-hours for weekday, 72-hours for weekend) Provide outpatient or pharmacy services utilization review Hours for this Position: M-F 8:00am to 5:00pm Requirements: Current Florida RN License 2+ years in recent medical/surgical or critical care experience 3+ years of Utilization Review / Case Management experience Strong reasoning ability: define problems, collect data, establish facts, and draw conclusions Advantages of this Opportunity: Competitive salary ($30/hr. to $32/hr.) Permanent position Benefits offered, Medical, Dental, and Vision Fun and positive work environment Interested in being considered? If you are interested in being considered for this position, PLEASE click the APPLY NOW button! Additional Information

Job DescriptionAbout us: Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked and each employee is valued. Please check out our company website at ************************ to learn more about us! **Bilingual in English and Spanish is required** Full benefits package offered on the first on the month following date of hire including: Medical, Dental, Vision, 401K plan with a 100% company match! Our company has doubled size and we have experienced exponential growth in membership from 2,000 members to over 10,000 members! Join our winning Solis Team! Position is fully onsite Monday-Friday. Location: 9250 NW 36th St, Miami, FL 33178. Position Summary: Under the supervision of the Health Services Director, the Utilization Management Nurse (LPN or RN) uses a multidisciplinary approach to organize, coordinate, monitor, evaluate, create and manage organization determinations and authorizations. These service requests will focus on selected complex medical and psychosocial needs of Solis Health Plans members. The UM Nurse is responsible for assuring the receipt of high quality, cost efficient medical outcomes for enrollees. This role works with Medical Directors, Authorization Coordinators and Service Coordinators to perform first level review to pre-certify elective services, procedures and tests utilizing established Care Coordination polices and protocols, Solis Health Plans benefit criteria, applicable regulatory review criteria and nationally accepted criteria for medical necessity determination. Main Key Responsibilities: Conduct concurrent and retrospective utilization review for inpatient, observation or SNF services. Conducts clinical reviews of proposed services against appropriate criteria/guidelines to determine medical necessity, benefit eligibility, and network contract status. Work with Medical Directors, Program Leadership and Solis Health Plans Provider Relations Teams to identify and mitigate facility barriers associated with the ability to make timely decisions. Identify, align and utilize health plan and community resources that impact high-risk/high cost care. Act as liaison between assigned facilities, members/families, and Solis Health Plans. Clarify policies/procedures and member benefits as needed. Authorizes services, coordinates care, and ensures timeliness and coordination of healthcare services, in compliance with department and regulatory standards, seeking supplemental services when appropriate or when needed. Assess enrollee needs and monitor progress toward goals at all times, communicating findings and status with members of the enrollee's primary care team. Ensure optimal delivery of safe quality health care to members, while maximizing resources and containing costs, and facilitate continual patient-centered and outcome-driven health performance improvement activities. Review enrollees with the Medical Directors and Primary Care Teams and advocates for Administration Exception considerations as appropriate. Facilitate communications between the facility, providers, and the PCT in order to effect and influence a safe and effective discharge plan and care plan for the enrollee. Qualifications: Graduate from an accredited school of nursing, or Bachelors (or advanced) degree in nursing. Active and unrestricted licensure as a Registered Nurse in Florida. A minimum of three to five years clinical experience as a Registered Nurse in a clinical setting required. 2 years' experience as a Utilization Management nurse in a managed care payer preferred. One year experience as a case manager in a payer or facility setting highly preferred. Discharge planning experience highly preferred. What Sets Us Apart: Join Solis Health Plans as a Utilization Management Nurse and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!

Integrated Resources, Inc is a premier staffing firm recognized as one of the tri-states most well-respected professional specialty firms. IRI has built its reputation on excellent service and integrity since its inception in 1996. Our mission centers on delivering only the best quality talent, the first time and every time. We provide quality resources in four specialty areas: Information Technology (IT), Clinical Research, Rehabilitation Therapy and Nursing. Job Description License and Educational requirement: LCSW, LCPC or RN. A Masters degree is required for ALL licenses EXCEPT for the RN. A Bachelors degree is required for the RNs. Description: Under general supervision by management, and in collaboration with Medical Directors and other members of the clinical team, gathers and synthesizes clinical information in order to authorize services. Reviews health care services to determine consistency with contract requirements, coverage policies and evidence-based medical necessity criteria; collects and analyzes utilization information; assists with program processes for transitions across levels of care including discharge planning and ambulatory follow up activity. Serves as an expert resource on coverage policies, covered benefits, and medical necessity criteria. ESSENTIAL FUNCTIONS: - Develops and manages new enrollee transitions and those involving a change in provider relationships. Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company's procedures. - Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms. - In conjunction with providers and facilities, identifies, develops and monitors discharge plans. Collaborates with the Care Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care. - Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria. - Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence. - Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis. - Maintains an active work load in accordance with performance standards. - Works with community agencies as appropriate. - Participates in network development including identification and recruitment of quality providers as needed. - Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner. - Provides coverage of Nurse Line and/or Crisis Line as requested or required for position. Qualifications Requirements/Certifications: THIS IS A TEMP-TO-PERM POSITION. The candidate will work an 8 hour shift that could start between the hours of 8am - 10:30am. Caseload: 25-30 reviews per day. This position is 98% telephonic. Additional Information: The candidate MUST have BH experience. There will be rounds with a Doctor for 15 mins everyday. Travel maybe required to a local hospital with a mileage rate of $0.54/mile. The manager is looking for 3 years of Inpatient Medical experience, 3 years of Utilization experience, Concurrent Review experience and HMO exp. Training will be 3 - 4 weeks long that will include Code of Conduct, Systems App and Shadowing. Credentialing Paperwork will be completed during training. Additional Information Riya Khem Life Science Recruiter Integrated Resources, Inc. IT Life Sciences Allied Healthcare CRO Certified MBE |GSA - Schedule 66 I GSA - Schedule 621I DIRECT # - 732 -844-8721 | (W) # 732-549-2030 - Ext - 311 |(F) 732-549-5549

We are seeking an Utilization Management Coordinator to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations. About the Role: The Utilization Management Coordinator plays a critical role in ensuring that healthcare services are delivered efficiently and effectively by overseeing the review and authorization of medical treatments and procedures. This position is responsible for coordinating utilization management activities to optimize member care while controlling costs and adhering to regulatory requirements. The role involves collaborating with healthcare providers, insurance companies, and internal teams to evaluate the necessity and appropriateness of medical services. The Coordinator will analyze clinical data and documentation to support decision-making processes and ensure compliance with organizational policies and healthcare standards. Ultimately, this position contributes to improving member outcomes by facilitating timely access to necessary care and preventing unnecessary or redundant services. Minimum Qualifications: Associate degree in Health Administration, or a related healthcare field Minimum of 2 years of experience in utilization management, case management, or a related healthcare coordination role. Strong knowledge of healthcare regulations, insurance processes, and medical terminology. Proficiency in electronic health records (EHR) systems and utilization management software. Relevant experience may substitute for the educational requirement on a year-for-year basis. Preferred Qualifications: Bachelor's degree in Nursing, Health Administration, or a related healthcare field. Certification in Utilization Review (e.g., Certified Professional in Utilization Review - CPUR) or Case Management (e.g., CCM). Experience working within managed care organizations or health insurance companies. Advanced knowledge of clinical guidelines and healthcare quality improvement methodologies. Familiarity with regulatory requirements such as HIPAA, URAC, and NCQA standards. Demonstrated ability to lead or participate in cross-functional teams focused on utilization management initiatives. Responsibilities: Conduct thorough reviews of medical records and treatment plans to determine the medical necessity and appropriateness of requested services. Coordinate communication between healthcare providers, insurance representatives, and internal departments to facilitate timely authorization and appeals processes. Maintain accurate documentation of utilization management activities and decisions in compliance with regulatory and organizational standards. Monitor and analyze utilization data to identify trends, potential issues, and opportunities for process improvement. Assist in developing and implementing utilization management policies and procedures to enhance operational efficiency and member care quality.

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Founded in 2005, HealthSun is a local Medicare Managed Care Organization with administrative offices located in Coconut Grove, Florida. Serving more than 50,000 members, HealthSun is one of the fastest growing health plans in South Florida. As a local plan, we recognize the healthcare needs of our community and strive to provide our members with only the best service and experience possible. The Nurse Case Manager I is responsible for performing care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning. How You Will Make an Impact: Primary duties may include, but are not limited to: Ensures member access to services appropriate to their health needs Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. Coordinates internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. Assists in problem solving with providers, claims or service issues. Minimum Requirements: Requires BA/BS in a health related field and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. Current, unrestricted RN license in applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states. Preferred Skills, Capabilities & Experiences: Certification as a Case Manager is preferred. Bilingual English/Spanish highly preferred. MS Office Suite good working knowledge preferred. For URAC accredited areas the following applies: Requires BA/BS and 3 years of clinical care experience; or any combination of education and experience, which would provide an equivalent background. Current and active RN license required in applicable state(s). Multi-state licensure is required if this individual is providing services in multiple states. Certification as a Case Manager and a BS in a health or human services related field preferred. Job Level: Non-Management Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ******************************************** for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Psychiatric Nurse Practitioner or Physician Assistant Schedule: Full-Time | Must be available Tuesday-Thursday Setting: Detox & Residential Treatment Program We are seeking an experienced Psych NP or PA to join our residential behavioral health program near Palm Springs, CA. This role is primarily psychiatric, working within a detox/residential program in Cathedral City, with occasional medical support as appropriate. Candidates must have strong substance abuse (SA) experience and be comfortable working with dual-diagnosis patients. Providers with a Psych NP, dual Psych/FNP, or PA background are encouraged to apply-must be willing to manage both psychiatric and medical needs as required. Key Responsibilities: Provide psychiatric evaluation, diagnosis, and ongoing medication management for residential and detox patients. Support medical needs within scope, especially for dual-diagnosis and SA-related conditions. Collaborate with multidisciplinary clinical teams to ensure high-quality, patient-centered care. Maintain accurate and timely clinical documentation. Participate in care planning, treatment team meetings, and continuity-of-care efforts. Qualifications: Licensed Psych NP, Psych/FNP, or Physician Assistant in the state of California. Experience required-must have a background working with substance abuse (SA) populations. Comfortable treating both psychiatric and medical issues in a residential treatment setting. Strong communication and teamwork skills. Full Benefits Package Includes: Medical, dental, and vision coverage Paid time off and holidays CME allowance Retirement plan options Employer-paid/licensure support Additional wellness and employee assistance benefits Brian Keegan Principal iRecruitMD C. ************ F. ************* O. ************ ******************** ******************

Job Description With two decades of excellence, Kalologie Medspa stands as a premier destination for aesthetic and wellness treatments. Our team of highly trained experts is renowned for their personalized approach, providing safe, effective, and medically-proven treatments that achieve exceptional results. We are proud of our team based culture, with a genuine focus on well-being. As we continue to expand, we remain committed to our core values and a passionate pursuit of excellence. Position Overview: We are seeking experienced Registered Nurses(RN) to perform IV Infusion Therapy at our location inside Club Studio in Miami World Center. You thrive working in a fast-paced environment and are always willing to learn more and strengthen your skills to deliver the best service and results. The ideal candidate would have specialized training in infusion therapy. Key Responsibilities: Prepare and set up the IV infusion. Foster a calming atmosphere and closely monitor the IV administration process. Conduct client consultations to create customized treatment plans and deliver services that meet individual needs and goals. Educate clients on treatment processes, including detailed pre- and post-care instructions. Address client inquiries, respond to their needs, and manage expectations effectively. Ensure client safety and satisfaction throughout all treatments. Promote and suggest relevant retail products and additional services offered by the company. Maintain and sanitize equipment and manage inventory of products. Adhere to established treatment protocols. Keep detailed records, including client charts. Build and maintain a strong client base. Participate in training sessions and meetings as needed. Perform other assigned duties as required. Occasionally travel to other locations for training purposes. Qualifications: Active license as a Registered Nurse (RN), Nurse Practitioner (NP), Physician Assistant (PA) in the state of employment. Minimum of 2 years of relevant experience preferred. Experience in a clinical setting is a plus. Exceptional interpersonal and communication skills, with the ability to effectively interact with clients, colleagues, and managers. Ability to multitask, stay attentive to client needs, and adapt to business requirements. Strong team player with the ability to take initiative and work independently. Availability to work evenings and weekends is required. Kalologie offers a competitive salary with flexible schedules, generous service discounts, and ongoing training opportunities on new techniques, equipment and products. We promote continued growth and development through our rapidly expanding medical aesthetic clinics.

Must posses a diploma from an accredited nursing school. Current certification as Registered Nurse (RN) with minimum two - three years clinical experience. Must be able to perform BLS (Basic Life Support) and ACLS (Advanced Cardiac Life Support) procedures and treatments. Some experience or a willingness and aptitude to learn simple laboratory procedures and operation of an x-ray machine. Emergency Room and General Practice background preferred. Experience with cardiac care, trauma, internal medicine preferred. Excellent communication skills and good command of the English language, knowledge of additional language(s) is a plus. The ship's nurse is an experienced Registered Nurse (RN) responsible to provide appropriate day-to-day health care to passengers and crew members aboard the cruise ship. The cruise ship nurse reports and works under the direction of the ship's lead nurse, ship's physician and ship's chief doctor. She/ he is called first in case of medical emergency aboard the cruise ship providing first aid care until arrival of the ship's physician. The ship nurse performs nursing care in a proficient, calm and professional manner during routine work shifts as well as duringa crisis, increased workload or emergency situations. She/ he initiates nursing intervention for non-urgent patients, such as but not limited to ice application, dressings, splints and bandages, calculates correct drug dosage and administers medication as per physicians prescription/order. She/ he also assist the physician with procedures/ treatments, document nursing interventions/ observations and sets up treatment rooms, checks emergency equipment, maintains established par levels of medical supplies/ medications. Working Place: Miami, FL, United States

Job DescriptionBenefits: Employee discounts Flexible schedule Opportunity for advancement Training & development Wellness resources Mobile IV Therapy Registered Nurse (Independent Contractor) Hydrology Wellness | Coral Gables, FL Pay: 30% of the infusion price, based on a per drip model + Tips. Schedule: Flexible | Part-Time | Contract | Weekends | On-call minimum 6 hours/week About Us Hydrology Wellness is a modern, patient-centered wellness center located in Coral Gables, FL. We specialize in concierge IV therapy and wellness services delivered directly to homes, offices, and hotels. Our mission is to enhance vitality and overall well-being through customized treatments administered by skilled professionals in a relaxing, elevated environment. About the Role We are seeking an experienced, charismatic, and highly skilled Registered Nurse (RN) to join our mobile IV therapy team. This is an independent contractor position ideal for nurses who want schedule flexibility, autonomy, and an opportunity to grow within the health and wellness industry. Responsibilities Perform patient assessments and obtain informed consent before treatment Administer IV infusions and intramuscular (IM) wellness injections following internal protocols Provide exceptional client care and post-treatment follow-ups Document treatment notes accurately in compliance with HIPAA Educate clients on the benefits and potential effects of therapies Travel to client homes, offices, or hotel rooms (primarily in Miami, Coral Gables & other surrounding neighborhoods) Maintain professionalism and a high standard of customer service Build rapport with clients to support retention and referrals Lead outreach to establish B2B agreements Requirements Active and unrestricted RN license in Florida Minimum 2 years of clinical experience (ICU, ER, NICU, Pre-Op/PACU preferred) Demonstrated expertise in IV insertion (minimum 2,000+ IVs started preferred) BLS and ACLS certifications required Reliable transportation and willingness to travel up to 20 miles per appointment Professional liability insurance (e.g., through NSO) Tech-savvy and organized, with excellent time management skills Willing to purchase & maintain your own basic medical supplies Clean background check and valid drivers license Promote tailored membership options designed to support each clients health and wellness goals. Preferred Qualifications Previous experience in mobile IV or concierge care Familiarity with wellness, aesthetics, or vitamin therapy Existing network or client base in South Florida is a plus A growth mindset and willingness to be incentivized for sales, including upselling and generating referrals and retention. Bilingual in Spanish is highly valued What We Offer Nurses receive a 30% commission on each infusion, calculated per individual drip session. Flexible scheduling you choose your hours Attractive pay structure with extra bonuses for successful upsells and client referrals. Employee discounts on wellness services Growth opportunities with a fast-expanding wellness brand Benefit from exclusive drip therapy discounts to support your wellness as you grow your income. Physical Setting Patient homes, offices, hotel rooms Hydrology Wellness location (as needed) Apply Today Ready to provide care in a more flexible and empowering setting? Submit your resume and complete the nursing skill assessment to get started. Learn more at: *************************

MDW Aesthetics - Brickell, Miami Compensation: $70-$100 per hour MDW Aesthetics is a modern, luxury medical spa located in the heart of Miami. We specialize in aesthetic injectable treatments, microneedling, and wellness services that help patients look and feel their best. We are a high-performance, high-standards, and high-vibe environment. Our team is warm, collaborative, and deeply passionate about aesthetics. Currently, we have three talented nurse injectors who work together seamlessly - and we are excited to welcome another injector who thrives in a supportive, healthy, and fun culture. Requirements We are seeking an experienced Aesthetic Nurse Injector to join our growing team. This role is ideal for someone who takes pride in delivering exceptional results, loves connecting with patients, and enjoys working in a beautiful, positive environment. This position starts part-time, with the opportunity to grow into full-time based on performance and patient demand, and interest. You will play an essential role in: Performing aesthetic injections (neurotoxins, dermal fillers, PRP) Conducting detailed consultations Creating individualized treatment plans Educating patients on procedures, safety, and aftercare Maintaining MDW's gold-standard hygiene, safety and documentation protocols Supporting our team-based approach to patient care Required Qualifications Active Nurse Practitioner (NP) license in Florida - required Minimum 1-2 years of nursing experience Minimum 3 years of aesthetic injecting experience (neurotoxins + fillers) Strong knowledge of facial anatomy, safety, and complication management Ability to work Saturdays Comfortable in a fast-paced, high-end clinic Excellent communication and patient-relationship skills Strong attention to detail and documentation accuracy Preferred Qualifications Skilled in laser treatments or willingness to learn Spanish speaking Occasional travel availability Has their own clientele is a bonus not a must Benefits We don't just hire people - we build a team. And at MDW, you'll feel the difference. ⭐ Compensation & Schedule $70-$100/hour depending on experience Part-time with ability to grow into full-time ⭐ A Beautiful, Healthy Work Culture Supportive team of 3 experienced nurse injectors Positive, fun, and collaborative atmosphere A workplace centered around respect, kindness, and growth Leadership that values work-life balance and team wellness ⭐ Professional Growth & Education Ongoing training and development Opportunity to learn new devices, techniques, and treatments Support for attending courses, workshops, and industry events ⭐ Employee Perks Employee discounts on treatments Family-and-friends treatment discounts Access to new technologies and products Beautiful, modern clinic setting in Brickell Paid Parking by MDW Time off/Flexible Schedule ⭐ Future Opportunity Ability to grow with the company Potential for increased hours, senior injector status, or lead roles Who We're Looking For Someone who: Loves aesthetics and artistry Has a warm, upbeat, welcoming personality Thrives in a team environment Delivers consistent, safe, beautiful results Values continual learning and self-development Wants to grow with a thriving, modern Miami medspa

Job Description MDW Aesthetics - Brickell, Miami Compensation: $70-$100 per hour About MDW Aesthetics MDW Aesthetics is a modern, luxury medical spa located in the heart of Miami. We specialize in aesthetic injectable treatments, microneedling, and wellness services that help patients look and feel their best. We are a high-performance, high-standards, and high-vibe environment. Our team is warm, collaborative, and deeply passionate about aesthetics. Currently, we have three talented nurse injectors who work together seamlessly - and we are excited to welcome another injector who thrives in a supportive, healthy, and fun culture. Requirements We are seeking an experienced Aesthetic Nurse Injector to join our growing team. This role is ideal for someone who takes pride in delivering exceptional results, loves connecting with patients, and enjoys working in a beautiful, positive environment. This position starts part-time, with the opportunity to grow into full-time based on performance and patient demand, and interest. You will play an essential role in: Performing aesthetic injections (neurotoxins, dermal fillers, PRP) Conducting detailed consultations Creating individualized treatment plans Educating patients on procedures, safety, and aftercare Maintaining MDW's gold-standard hygiene, safety and documentation protocols Supporting our team-based approach to patient care Required Qualifications Active Nurse Practitioner (NP) license in Florida - required Minimum 1-2 years of nursing experience Minimum 3 years of aesthetic injecting experience (neurotoxins + fillers) Strong knowledge of facial anatomy, safety, and complication management Ability to work Saturdays Comfortable in a fast-paced, high-end clinic Excellent communication and patient-relationship skills Strong attention to detail and documentation accuracy Preferred Qualifications Skilled in laser treatments or willingness to learn Spanish speaking Occasional travel availability Has their own clientele is a bonus not a must Benefits We don't just hire people - we build a team. And at MDW, you'll feel the difference. ⭐ Compensation & Schedule $70-$100/hour depending on experience Part-time with ability to grow into full-time ⭐ A Beautiful, Healthy Work Culture Supportive team of 3 experienced nurse injectors Positive, fun, and collaborative atmosphere A workplace centered around respect, kindness, and growth Leadership that values work-life balance and team wellness ⭐ Professional Growth & Education Ongoing training and development Opportunity to learn new devices, techniques, and treatments Support for attending courses, workshops, and industry events ⭐ Employee Perks Employee discounts on treatments Family-and-friends treatment discounts Access to new technologies and products Beautiful, modern clinic setting in Brickell Paid Parking by MDW Time off/Flexible Schedule ⭐ Future Opportunity Ability to grow with the company Potential for increased hours, senior injector status, or lead roles Who We're Looking For Someone who: Loves aesthetics and artistry Has a warm, upbeat, welcoming personality Thrives in a team environment Delivers consistent, safe, beautiful results Values continual learning and self-development Wants to grow with a thriving, modern Miami medspa

Why Work at Concerto? What is in it for you? Three (3) day work week Competitive pay Nurse to patient's ratio Clinical/Corporate Career Advancement Medical, dental, vision, short- and long-term disability benefits Pet Insurance 401k match of 50% up to 6% of salary PTO Paid Holidays Discounts through Nectar Employer Paid Employee Assistance Program Who Are We? Concerto Renal Services is an industry leader in sub-acute hemodialysis within a skilled nursing facility and/or long-term care facility. We are a rapidly expanding business with a simple mission: reimagining dialysis care, one community at a time. Our model focuses on ensuring those with end-stage renal disease receive the best possible care through a more convenient, centralized, continuous care model. Why is this Role Essential? Concerto is seeking a Dialysis Nurse to join its team! The Dialysis Nurse supervises dialysis care in accordance with policy, procedure and training and in compliance with state and federal regulations. Assures responsibility for the unit and works collaboratively with members of the hemodialysis healthcare team. Supervises care given by dialysis technicians while assuming a ‘hands on' role and fostering a team approach to patient care. What Will You Do? Patient Care & Education Provides direct hemodialysis care, performs assessments, administers medications, and educates patients on renal health, treatment, and self-care. Team Leadership & Supervision Delegates tasks to dialysis technicians, supervises their performance, and ensures compliance with clinical standards and regulations. Treatment Monitoring & Adjustment Monitors patient response to dialysis, adjusts treatment plans as needed, and ensures accurate documentation of interventions and outcomes. Collaboration & Communication Works closely with physicians and healthcare team members to coordinate care, report critical lab results, and ensure continuity of treatment. Documentation & Compliance Maintains accurate electronic medical records, ensures timely completion of care plans, and adheres to safety and regulatory protocols. Qualifications You Might Be a Good Fit If You are... Compassionate and Empathetic A Critical Thinker and Problem-Solver An Individual who Thrives in a Team Environment An Individual with Excellent Communication Skills Purpose-driven What's Required? Graduate of an accredited school of Nursing Current State appropriate or Compact RN License Minimum of one (1) year of nursing experience in any practice area Minimum of three (3) months of Dialysis experience required BLS Provider certification Physical Requirements & Work Environment This role requires successful completion of the Ishihara Color Blindness Test to ensure accurate color perception in a clinical setting. It also involves prolonged walking, standing, stooping, and bending, with the ability to lift up to 25 lbs. Strong focus and attention to detail are essential. The work environment includes temperature control, moderate noise levels, and potential exposure to infectious materials. Other Duties Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice. Compensation $38 - $50 per hour Hourly rate is dependent upon several factors, including but not limited to the following: a candidate's experience in this position and/or the dialysis industry in general, location of the position in question, urgency of company need, timeline of required to fill position, and other potential and/or applicable factors that emerge from time to time.