Remote Utilization Management RN, Swansea, IL


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Requisition Number: 2189436
Job Category: Nursing
Primary Location: Swansea, IL
(Remote considered)

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Come make an impact on the communities we serve as we help advance health equity on a global scale. Here, you will find talented peers, comprehensive benefits, a culture guided by diversity and inclusion, career growth opportunities and your life’s best work.SM

The Utilization Management Nurse RN provides feedback as requested to enhance negotiations with payers. Assesses for accuracy in the assignment of patient class (status) to reflect congruence with clinical condition, physician intent and utilization review outcomes with current rules and regulatory requirements. Supports the medical chart audit process by ensuring accurate, timely and informative clinical review documentation and support of medical necessity/level of care.  Supports denials management by documenting activities related to denials adjudication according to departmental guidelines and actively works to overturn threatened denial activities.

Schedule: Monday to Friday from 8:00am to 5:00pm CST time zone

If you reside in Missouri, Illinois, Wisconsin, or Oklahoma, you’ll enjoy the flexibility to telecommute* as you take on some tough challenges.

Primary Responsibilities:

  • Maintains professional and concise telephonic or written communication skills when engaging front line staff physicians or insurers
  • Follows established standards of work applicable to role
  • Meets established metrics for accuracy and productivity
  • Participates in continuous performance or process improvement based on identified trends or opportunities
  • Assesses planned or admitted designated patient groups for identification of status and admission necessity
  • Selects the appropriate criteria set based on clinical findings at the time of review
  • Includes clear documentation of the data supporting the proposed level of care
  • Documents findings in the client’s EMR per established standards of work
  • For patients meeting inpatient criteria with an MD inpatient order, ensures initial proactive UR contact with appropriate payor based on established process (example; fax/portal/phone)
  • Engages attending physicians or ED physicians as appropriate if clinical information is incomplete or needs clarification
  • Maintains and demonstrates appropriate clinical knowledge to assist physicians in providing documentation of severity of illness and intensity of service to assure that criteria for acute hospitalization are met
  • Engages attending physicians or ED physicians as appropriate if clinical information is incomplete or needs clarification
  • Follows established escalation standard of work for those cases with a mismatch of review finding and physician status order
  • Follows established standards of work for concurrent denials
  • Coordinates with hospital-based Case Management staff to help identify and manage inappropriate resource utilization
  • Independently utilizes time constructively by prioritizing and organizing assignments for maximum productivity
  • Employees are expected to comply with all regulatory requirements, including CMS and Joint Commission Standards
  • Provide concurrent state review services based on needs/request

What are the reasons to consider working for UnitedHealth Group?   Put it all together – competitive base pay, a full and comprehensive benefit program, performance rewards, and a management team who demonstrates their commitment to your success. Some of our offerings include:

  • Paid Time Off which you start to accrue with your first pay period plus 8 Paid Holidays
  • Medical Plan options along with participation in a Health Spending Account or a Health Saving account
  • Dental, Vision, Life& AD&D Insurance along with Short-term disability and Long-Term Disability coverage
  • 401(k) Savings Plan, Employee Stock Purchase Plan
  • Education Reimbursement
  • Employee Discounts
  • Employee Assistance Program
  • Employee Referral Bonus Program
  • Voluntary Benefits (pet insurance, legal insurance, LTC Insurance, etc.)
  • More information can be downloaded at:

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

  • Associate’s Degree (or higher) in Nursing
  • Unrestricted Compact State Registered Nurse (RN) Licensure
  • 3+ years of recent clinical experience in healthcare as a Registered Nurse
  • 2+ years of experience as a Utilization Management RN
  • A designated home work space with access to install secure high-speed internet via cable/DSL

Preferred Qualifications

  • Bachelor of Science in Nursing (or higher)
  • Experience in utilization review, concurrent review, or risk management
  • Previous experience with InterQual or MCG
  • Experience in a telephonic role

*All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.