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Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together.
The Clinical Utilization Management Nurse is responsible for performing utilization review activities to ensure appropriate use of medical resources, compliance with regulatory requirements, and adherence to clinical best practices. This role supports acute hospital utilization management, helps prevent payer denials, and contributes to maintaining revenue integrity. The nurse collaborates with physicians, case managers, and interdisciplinary teams to promote efficient, high-quality patient care.
You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.
Primary Responsibilities:
- Conduct timely and accurate admission, concurrent, and discharge reviews to determine medical necessity and appropriate level of care
- Apply InterQual/MCG criteria and payer guidelines to support clinical decisions.
- Document utilization review findings in electronic medical records and utilization management systems
- Participate in interdisciplinary rounds and collaborate on discharge planning to reduce avoidable days and length of stay
- Monitor and escalate potential or actual payer denials for timely resolution
- Perform documentation audits to ensure completeness and accuracy related to utilization criteria
- Stay current on regulatory and payer policy updates and apply them in daily reviews
- Support education efforts by sharing updates on documentation standards and regulatory requirements with clinical teams
- Contribute to quality and compliance initiatives as directed by leadership
- Maintain accurate records of reviews, authorizations, and outcomes for reporting purposes
- Advocate for patients to ensure appropriate care while balancing resource utilization
Working Conditions:
- Hours per FTE, telecommuter
- Fast-paced clinical environment with frequent collaboration across departments
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:
- Active, unrestricted RN or LPN license in the state of residency
- 3+ years of experience in utilization review or case management in an acute care setting
- Solid knowledge of InterQual/MCG criteria, CMS regulations, and payer guidelines
- Proficiency in electronic medical records and utilization management software
Preferred Qualifications:
- Certification in Utilization Management or Case Management (e.g., ACM, CCM)
- Experience with Epic EMR, Cerner Powerchart
- Familiarity with healthcare payer operations
*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $60,200 to $107,400 annually based on full-time employment. We comply with all minimum wage laws as applicable.
Application Deadline: This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.
At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes – an enterprise priority reflected in our mission.
