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Optum Health Utilization Review Jobs (NOW HIRING)

Franciscan Health

Utilization Review Coordinator

Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care ... Perform concurrent reviews for appropriateness of utilization to optimize clinical and financial ...

ICBD

Utilization Review Specialist

Lauderdale Lakes, FL · On-site

$55K - $70K/yr

Best in Business, Health Services. About the Role As a Utilization Review Specialist, you will play a pivotal role in ensuring the efficient and effective utilization of healthcare resources. The UR ...

Oscar Health

Utilization Review Nurse

Tempe, AZ · 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 ...

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How much do optum health utilization review jobs pay per hour?

As of Jul 13, 2026, the average hourly pay for optum health utilization review in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

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 is an Optum Health Utilization Review job?

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, and why are they important?

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.

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Optum Health Utilization Review jobs near you
Infographic showing various Optum Health Utilization Review job openings in the United States as of July 2026, with employment types broken down into 1% As Needed, 76% Full Time, 18% Part Time, and 5% Contract. Highlights an 96% Physical, 1% Hybrid, and 3% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.

Behavioral Health Utilization Review Registered Nurse

Hines and Associates, Inc

Rockford, IL • On-site, Remote

$57K - $62K/yr

Full-time

Medical, Dental, Vision, Life, Retirement

Re-posted 4 days ago

Job description

Nurses - are you looking for a change? Want to work no nights, no weekends, and no holidays? Check out Hines & Associates!
*Must have Mental Health and/or Substance Abuse experience*
ABOUT US:
Hines is a nationwide, independent leader in personalized managed health care, focused on what's important to you-comprehensive services with the program excellence and cost containment that you demand. Hines & Associates, Inc.'s reputation as an industry leader is founded on over three decades of innovative and professional health care excellence. Serving all aspects of the industry, Hines is committed to conserving health care dollars while ensuring quality care through effective programs and personalized service.
WHAT WE OFFER:
  • Competitive salary and benefits, including medical, dental, vision, long-term care, short-term disability, long-term disability, company paid and voluntary life insurance. Critical Illness, accident insurance and flexible spending also available!
  • 401k plan with company match, fully vested after 1 year.
  • No weekends and nights!
  • Paid Holidays
  • Work-life balance.
  • Remote setting

ROLE DESCRIPTION:
This individual will utilize clinical knowledge and communication skills to obtain patient specific information regarding patient condition and proposed treatments and procedures to determine if illness and/or proposed services meet acceptable criteria sets and acceptable nursing practice guidelines for outpatient treatment or inpatient confinement. This individual will certify treatment for confinement when criteria and/or practice guidelines are met, in accordance with the health benefit plan, disability, workers compensation regulations and state and federal regulations. If these conditions do not appear to be met, this individual will defer decision to a second level reviewer. This individual interfaces with case managers and disease management nurses on active cases involved in other Hines' programs.
*****This is a Monday through Friday position, 9:30 AM to 6:00 PM.******
RESPONSIBILITIES AND PERFORMANCE:
  • Completes first level reviews within the scope of practice relevant to the clinical area(s) addressed in the initial clinical review. General Medical-Surgical nursing is sufficient to be relevant to the clinical areas addressed in most initial clinical reviews. .
  • Demonstrates ability to assess a patient's current medical status, including complications and untoward events, which may require additional intervention. Provides certification of medical, disability and workers compensation cases.
  • Demonstrates a thorough understanding of criteria sets and their limitations including when a second level review is required.
  • Evaluates appropriateness of current plan of care.
  • Assesses aftercare needs, implements discharge planning and/or case management referral in a timely manner.
  • Maintains knowledge of current advances and trends in medical care.
  • Demonstrates knowledge of URAC guidelines, Hines policies and procedures, and standards of practice and their revisions. Able to attain and maintain the minimal quality assurance performance standards.
  • Demonstrates assertiveness in completion of precertification and concurrent review within the guidelines of URAC, disability, workers compensation regulations, and state and federal requirements and according to the Hines policies and procedures.
  • Performs onsite evaluations as needed or requested.
  • Additional responsibilities as assigned.

PM21
COMMUNICATION:
  • Communicates with hospital staff, physicians, other providers and Hines customer contacts in a competent, calm, effective and professional manner.
  • Effectively communicates the need to refer to a higher-level review for questionable plans of treatment.
  • Provides written documentation concerning the clinical information obtained regarding the patient's status, benefit and claim concerns, and validation of criteria.
  • Communicates knowledge of policies and procedures, URAC guidelines, disability and workers compensation regulations, state and federal requirements, and standards of practice.

PERSONAL AND PROFESSIONAL:
  • Participates in self-evaluation by identifying areas of strength and limitations and offers and accepts constructive criticism.
  • Creative and assertive.
  • All First Level Reviewers are required to sign and honor a confidentiality statement at the time of hire and annually at the time of performance reviews.

Requirements
QUALIFICATIONS:
  1. Registered Nurse with valid, unrestricted, current nursing license in the state or territory of the United States where employed. For mental health/substance abuse, licensed medical professional with an unrestricted license in the state or in a state that has licensure reciprocation with the state of the office location the employee is working in may perform first level reviews. Accepted licensure includes but is not limited to RN, LMSW, LMHC.
  2. Must have Mental Health or Substance Abuse experience.
  3. Successful completion of UR nurse orientation program.
  4. Minimum of 3 years recent acute clinical practice required, 5 years preferred.
  5. Managed care, disability or workers compensation experience helpful but not mandatory.
  6. Customer service oriented.

*Hines welcomes diversity and as an equal opportunity employer all qualified applicants will be considered regardless of race, religion, color, national origin, sex, age, sexual orientation, gender identity, disability or protected veteran status.*
Salary Description
$57,244 - $62,180 per year

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