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Optum Health Utilization Review Jobs in Texas (NOW HIRING)

Oscar Health

Utilization Review Nurse

Dallas, TX · Remote

$35 - $45.94/hr

We're hiring a Utilization Review Nurse to join our Utilization Review team. About the role: You ... We're on a mission to change health care -- an experience made whole by our unique backgrounds and ...

Bracane Co

Utilization Review Nurse

Plano, TX · Remote

... Health Care Insurance Company. * Knowledge of medical terminology and procedures. * Verbal and ... Utilization management experience LOCATION: REMOTE in Texas ( Richardson area ? Dallas/Collin ...

Medix

Utilization Review Nurse

Fort Worth, TX · On-site

$38.46 - $43.27/hr

Job Summary Our client is seeking a skilled Utilization Review Nurse to join their team. This role ... Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 ...

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Optum Health Utilization Review information

What is an Optum Health Utilization Review?

An Optum Health Utilization Review job involves assessing medical necessity, appropriateness, and efficiency of healthcare services. Professionals in this role review patient records, insurance claims, and treatment plans to ensure compliance with industry standards and policies. They collaborate with healthcare providers, insurance companies, and patients to optimize care while managing costs. The position requires strong clinical knowledge, attention to detail, and familiarity with medical guidelines. It plays a crucial role in improving healthcare quality and reducing unnecessary expenses.

What are the key skills and qualifications needed to thrive in the Optum Health Utilization Review position?

To excel in an Optum Health Utilization Review role, you typically need a background in nursing or a related clinical field, a valid RN license, and familiarity with healthcare policies and guidelines. Experience with utilization management software, electronic medical records (EMR) systems, and potentially certifications such as CCM (Certified Case Manager) are highly valued. Strong analytical skills, attention to detail, and effective communication are important soft skills for evaluating medical necessity and collaborating with providers. These competencies ensure accurate, compliant review processes that support optimal patient care and organizational efficiency.

What are some common challenges faced by Optum Health Utilization Review specialists and how does the team address them?

Optum Health Utilization Review specialists often encounter challenges such as staying current with frequently changing healthcare regulations, handling complex medical cases, and managing high caseloads with tight deadlines. The team fosters a collaborative environment where members can consult with medical directors, other clinical reviewers, and support staff to resolve difficult cases and clarify policies. Regular training sessions, ongoing education, and access to up-to-date resources help team members stay informed and manage these challenges effectively. This supportive structure enables specialists to maintain high accuracy and efficiency while delivering quality outcomes for patients and providers.

What are the most commonly searched types of Optum Health Utilization Review jobs in Texas?

The most popular types of Optum Health Utilization Review jobs in Texas are:

What are popular job titles related to Optum Health Utilization Review jobs in Texas?

For Optum Health Utilization Review jobs in Texas, the most frequently searched job titles are:

What job categories do people searching Optum Health Utilization Review jobs in Texas look for?

The top searched job categories for Optum Health Utilization Review jobs in Texas are:

What cities in Texas are hiring for Optum Health Utilization Review jobs?

Cities in Texas with the most Optum Health Utilization Review job openings:

Optum Health Utilization Review jobs near you
Infographic showing various Optum Health Utilization Review job openings in Texas as of August 2026, with employment types broken down into 2% As Needed, 79% Full Time, 14% Part Time, and 5% Contract. Highlights an 95% Physical, 1% Hybrid, and 4% Remote job distribution.

Remote UTILIZATION REVIEW NURSE - RN

Houston, TX • On-site

Nexus Health Systems
Health Care and Social Assistance • 501 - 1,000 employees

6.3

Company rating: 6.3 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

Respectful managers

Learn more about Nexus Health Systemsexternal

Other

Medical, Dental, Vision, Retirement, PTO

Posted 21 days ago

Job description

Remote Utilization Review Registered Nurse (UR RN)

Nexus Health Systems is seeking an experienced Utilization Review Registered Nurse (UR RN) to join our growing Utilization Management team. This fully remote position plays a critical role in ensuring patients receive medically necessary, high-quality care while promoting appropriate resource utilization and regulatory compliance.

If you're a detail-oriented RN with experience in utilization review, case management, or behavioral health and enjoy collaborating with interdisciplinary teams to improve patient outcomes, we'd love to hear from you.

What You'll Do
  • Conduct concurrent and retrospective utilization reviews to determine medical necessity and appropriate level of care.
  • Apply evidence-based criteria, including InterQual (or similar), to support clinical decision-making and payer compliance.
  • Collaborate with physicians, case managers, and interdisciplinary teams to facilitate timely authorizations, discharge planning, and appropriate transitions of care.
  • Review clinical documentation to ensure accuracy, completeness, and compliance with payer and regulatory requirements.
  • Manage insurance authorizations, denials, appeals, and level-of-care determinations.
  • Monitor utilization trends and contribute to quality improvement initiatives that enhance patient outcomes and operational efficiency.
  • Participate in multidisciplinary utilization review meetings and provide recommendations to optimize care delivery.
  • Maintain accurate documentation within the electronic health record (EHR) while ensuring HIPAA compliance.
Qualifications

Required

  • Associate Degree in Nursing (ADN) from an accredited nursing program.
  • Current, unrestricted Texas RN license or Compact RN license.
  • Minimum of 2 years of acute care clinical nursing experience.
  • At least 3 years of Utilization Review or Case Management experience involving complex medical/surgical and/or behavioral health patients.
  • Strong knowledge of payer guidelines, medical necessity criteria, and utilization management principles.
  • Excellent critical thinking, communication, and organizational skills.
  • Proficiency with electronic health records (EHRs) and Microsoft Office applications.

Preferred

  • Bachelor of Science in Nursing (BSN).
  • Experience with InterQual or MCG criteria.
  • Behavioral health utilization review experience.
  • Experience with Meditech.
  • Professional certifications such as CCM, CPHQ, or HCQM.
Why Nexus Health Systems?

At Nexus Health Systems, our mission is to improve lives through compassionate, high-quality care. As a member of our Utilization Review team, you'll collaborate with dedicated healthcare professionals while helping ensure patients receive the right care at the right time.

We offer:

  • Competitive compensation
  • Comprehensive medical, dental, and vision benefits
  • Paid time off and company holidays
  • 401(k) with company match
  • Professional development and continuing education opportunities
  • A collaborative, mission-driven culture
  • Fully remote work environment

If you're ready to make a meaningful impact in healthcare while enjoying the flexibility of working remotely, we'd love to hear from you.

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