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Optum Utilization Review Nurse Jobs (NOW HIRING)

Oscar Health

Utilization Review Nurse

Miami, FL · Remote

$35 - $45.94/hr

We're hiring a Utilization Review Nurse to join our Utilization Review team. About the role: You will perform frequent case reviews, check medical records and speak with care providers regarding ...

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 will perform frequent case reviews, check medical records and speak with care providers regarding ...

Oscar Health

Utilization Review Nurse

Atlanta, GA · Remote

$35 - $45.94/hr

We're hiring a Utilization Review Nurse to join our Utilization Review team. About the role: You will perform frequent case reviews, check medical records and speak with care providers regarding ...

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 will perform frequent case reviews, check medical records and speak with care providers regarding ...

AbsoluteCare

Utilization Review Nurse

New Orleans, LA · On-site

The Utilization Review Nurse ensures appropriate utilization of health services by performing initial, concurrent and retrospective clinical case reviews. This role collaborates and communicates with ...

AbsoluteCARE

Utilization Review Nurse

New Orleans, LA · On-site

The Utilization Review Nurse ensures appropriate utilization of health services by performing initial, concurrent and retrospective clinical case reviews. This role collaborates and communicates with ...

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Optum Utilization Review Nurse information

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$42

$68

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

As of Jul 27, 2026, the average hourly pay for optum utilization review nurse 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 the key skills and qualifications needed to thrive as an Optum Utilization Review Nurse, and why are they important?

To thrive as an Optum Utilization Review Nurse, you need strong clinical assessment skills, a current RN license, and experience in case management or utilization review. Familiarity with clinical documentation systems, InterQual or Milliman Care Guidelines, and managed care regulations is typically required. Attention to detail, critical thinking, and effective communication are crucial soft skills for this role. These competencies are vital to ensure appropriate care decisions, regulatory compliance, and collaboration with interdisciplinary teams for optimal patient outcomes.

What is the difference between Optum Utilization Review Nurse vs Optum Case Manager?

AspectOptum Utilization Review NurseOptum Case Manager
CredentialsRN license, certifications in case management or utilization review often preferredRN license, case management certification often preferred
Work EnvironmentReviewing medical records, assessing insurance claims, working in healthcare or insurance settingsCoordinating patient care, managing cases, working in healthcare or insurance settings
Employer & IndustryHealth insurance companies, healthcare providers, utilization review departmentsHealth insurance companies, healthcare organizations, patient advocacy

Optum Utilization Review Nurses primarily evaluate medical necessity and approve or deny insurance claims, focusing on utilization review. In contrast, Optum Case Managers coordinate patient care, develop treatment plans, and support patient needs. Both roles require nursing credentials and work within healthcare or insurance environments, but their core responsibilities differ in focus and scope.

How does an Optum Utilization Review Nurse typically collaborate with physicians and other healthcare professionals during the review process?

As an Optum Utilization Review Nurse, you will frequently interact with physicians, case managers, and other healthcare providers to assess the medical necessity and appropriateness of patient care. This collaboration often involves reviewing clinical documentation, participating in multidisciplinary meetings, and communicating findings or recommendations to ensure quality and cost-effective care. Building strong professional relationships and maintaining clear, respectful communication are key to facilitating smooth care transitions and achieving optimal patient outcomes. This collaborative approach helps ensure that all parties are aligned with evidence-based guidelines and organizational policies.

What does an Optum Utilization Review Nurse do?

An Optum Utilization Review Nurse is responsible for reviewing medical records and patient cases to ensure that healthcare services provided are medically necessary and compliant with insurance guidelines. They evaluate treatment plans, collaborate with healthcare providers, and help determine coverage decisions for patients. By assessing the appropriateness of care, they help manage healthcare costs and improve patient outcomes. Their work involves communication with physicians, patients, and insurance representatives to ensure efficient and effective care delivery.
More about Optum Utilization Review Nurse jobs
What cities are hiring for Optum Utilization Review Nurse jobs? Cities with the most Optum Utilization Review Nurse job openings:
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Optum Utilization Review Nurse jobs near you
Infographic showing various Optum Utilization Review Nurse job openings in the United States as of July 2026, with employment types broken down into 3% As Needed, 57% Full Time, 15% Part Time, and 25% Contract. Highlights an 99% Physical, and 1% Remote job distribution, with an average salary of $87,946 per year, or $42.3 per hour.
Utilization Review Nurse

Utilization Review Nurse

Health Business Solutions LLC

Cooper City, FL

Full-time

Posted 18 days ago

Job description

Job Summary: We are seeking a highly motivated and experienced Utilization Review Nurse to join our team. The Utilization Review Nurse will play a crucial role in supporting our clients in the healthcare industry by providing expert clinical guidance, facilitating effective utilization management, and ensuring revenue cycle efficiency. This position offers a unique opportunity to combine clinical expertise with revenue cycle management knowledge.

Key Responsibilities:

· Clinical Assessment: Conduct comprehensive clinical assessments of medical records to ensure patients are receiving appropriate care at the correct level of service.

  • Care Coordination: Collaborate with interdisciplinary healthcare teams to coordinate patient care and treatment plans, ensuring the most cost-effective and clinically appropriate care is provided.
  • Revenue Cycle Management: Utilize clinical expertise to support revenue cycle processes, including accurate coding, documentation improvement, and compliance with healthcare regulations.
  • Utilization Review:

a) Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays

b) Conduct initial admission, continuing stay, and 23-hour observations reviews for all patients

c) Support Utilization Review Coordinator team members on cases escalated for level of care determinations

d) Screen cases for Physician Advisor review

e) Collaborate with insurance companies on concurrently denied and high risk for denial cases

  • Documentation Improvement: Identify opportunities for improving clinical documentation to support accurate coding and billing processes, ultimately improving reimbursement.


  • Data Analysis: Analyze clinical and financial data to identify trends, opportunities for improvement, and areas of potential cost savings for clients.


  • Compliance: Stay up-to-date with healthcare regulations, guidelines, and policies to ensure all patient care and revenue cycle processes are in compliance with industry standards and regulatory requirements to ensure appropriate reimbursement.

Qualifications:

· Registered Nurse (RN) licensure required; must hold a USRN multi-state/compact nursing license.

· Bachelor of Science in Nursing (BSN) preferred.

· Case Management Certification (e.g., CCM) is a plus.

· Minimum of 3 years of clinical nursing experience, preferably in a hospital or acute care setting.

· Minimum 2 years of work experience in Utilization Review

· Strong understanding of revenue cycle management and healthcare reimbursement.

· Proficiency in medical coding and clinical documentation improvement.

· Excellent communication, interpersonal, and teamwork skills.

· Ability to work independently and make sound clinical and financial decisions.

· Strong analytical and problem-solving skills.

· Proficient in using healthcare information systems and technology.

· Commitment to maintaining patient confidentiality and ethical standards.

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