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Optum Utilization Review Nurse Jobs in Puerto Rico

UHS

PR · On-site

The Utilization Review (UR) Director is responsible for overseeing the utilization management ... Valid membership for Social Work and Psychiatric Nursing * A minimum of five years' experience in ...

San Juan Capestrano

Utilization Coordinator

San Juan, PR · On-site

Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...

Acadia Healthcare

PR · On-site

Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...

San Juan Capestrano

Utilization Coordinator

San Juan, PR · On-site

Conduct reviews, in accordance with certification requirements, of insurance plans or other managed ... Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides ...

Harboroaks

$60 - $85/hr

... utilization review processes to assure continuity for the most appropriate level of care for ... Clear and active nursing license in the state. * CPR and de-escalation/restraint certification ...

New

Acadia Healthcare

PR · On-site

... utilization review processes to assure continuity for the most appropriate level of care for ... Clear and active nursing license in the state. * CPR and de-escalation/restraint certification ...

Encompass Health

Case Manager

Manati, PR · On-site

$17 - $21.75/hr

Participate in utilization review process: data collection, trend review, and resolution actions ... For Nursing, must possess minimum of an Associate Degree in Nursing, RN licensure with BSN ...

UHS

PR

Provide backup to Utilization Review Department out of business hours including document in the ... Valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling ...

UHS

PR · On-site

Provide backup to Utilization Review Department out of business hours including document in the ... Valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling ...

UHS

PR · On-site

Provide backup to Utilization Review Department out of business hours including document in the ... Valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling ...

UHS

PR · On-site

Provide backup to Utilization Review Department out of business hours including document in the ... Valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling ...

DaVita

Inventory Clerk

Carolina, PR · On-site

$11.25 - $13.50/hr

... utilization of the dialysis facility inventory and inventory system in accordance with DaVita ... These must be reviewed with management. However, in general, the position requires the following ...

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Optum Utilization Review Nurse information

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.

What are the key skills and qualifications needed to thrive as an Optum Utilization Review Nurse?

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.

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 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.

What are popular job titles related to Optum Utilization Review Nurse jobs in Puerto Rico?

For Optum Utilization Review Nurse jobs in Puerto Rico, the most frequently searched job titles are:

What job categories do people searching Optum Utilization Review Nurse jobs in Puerto Rico look for?

The top searched job categories for Optum Utilization Review Nurse jobs in Puerto Rico are:

What cities in Puerto Rico are hiring for Optum Utilization Review Nurse jobs?

Cities in Puerto Rico with the most Optum Utilization Review Nurse job openings:

Optum Utilization Review Nurse jobs near you
Infographic showing various Optum Utilization Review Nurse job openings in Puerto Rico as of August 2026, with employment types broken down into 1% As Needed, 81% Full Time, 14% Part Time, 1% Temporary, and 3% Contract. Highlights an 88% Physical, 3% Hybrid, and 9% Remote job distribution.

DIRECTOR - UTILIZATION REVIEW

UHS

PR • On-site

Full-time

Re-posted 21 days ago

Universal Health Services rating

6.9

Company rating: 6.9 out of 10

Based on 254 frontline employees who took The Breakroom Quiz

454th of 898 rated healthcare providers

Job description

Responsibilities
Provides strategic leadership to the daily operations of the Utilization Review Department. The Utilization Review (UR) Director is responsible for overseeing the utilization management processes to ensure efficient, compliant, and clinical guideline-aligned care. Oversee the utilization reviews, organization determinations and appeals processes in accordance with established policies and procedures. The UR Director maintains full compliance with CMS regulatory standards for utilization reviews and appeals as outlined in the CMS Managed Care Manual, as well as local and national coverage determinations, the Puerto Rico Insurance Commissioner's Office, the Office of Personnel Management (OPM), and relevant accrediting bodies. Additionally, the UR Director must comply with URAC and NCQA standards. Ensure that denial and appeal letters are responded to in accordance with industry standards .
Responsibilities and essential duties:
  • Oversee Utilization Review Processes:
  • Leads the utilization review procedures in accordance with the standards set by all relevant accrediting and regulatory agencies, including URAC, CMS, NCQA, PR Insurance Commissioner's Office, and the Office of Personal Management (OPM), as well as by the health insurance industry, among others. Manage and supervise the UR team, setting standards for reviewing mental health services to ensure compliance with clinical protocols, and organizational policies.
  • Keep abreast of any legal or regulatory changes that impact on the UR functions and operations to ensure timely implementation.
  • Supervise the review process to ensure that requests for mental health treatment are approved or denied based on established clinical criteria and medical necessity guidelines.
  • Conduct regular audits of utilization reviews to ensure adherence to policies and procedures, documentation of cases in established tools, use of best practices, and ethical standards.
  • Available daily for case analysis, as required.
  • Responsible for making sure that the denial and appeal letters are documented and mailed in the timeframe established by regulatory organization and industry standards.
  • Identify potential risks related to mental health service delivery and utilization, including under-utilization or over-utilization of services.
  • Develop strategies to mitigate risks and improve the timeline to respond to preauthorization request through efficient resource management.
  • Ensure Compliance and Quality Control
  • Provides assertive, effective, and consistent supervision to assure quality control and service excellence.
  • Ensure compliance in the preparation and implementation of established corrective action plans and their timeframes as result of internal and external audit findings as required by FHC's and Client's Compliance Departments.
  • Ensure an effective communication with supervised personnel regarding the findings and plans that need implementation.
  • Assures that the census count of the members admitted to the different facilities is done daily to allocate the corresponding resources to assure compliance with utilization concurrent and retrospective reviews and authorization in the electronic platform, according to industry standards.
  • Contributes to the compliance with specific organizational and individual goals of the position based on the financial targets.
  • Complies with agencies recommendations responsible for monitoring our work, for example, health plans, CMS, NCQA, the Insurance Commissioner's Office, Office of Personal Management (OPM) and URAC.
  • Supervises the Interrater Reliability Tests with the VP of Clinical Affairs and Medical Director.
  • Analyze utilization data to identify trends, inefficiencies, and opportunities for cost-saving without compromising patient care.
  • Prepare and present reports on utilization trends, key performance indicators, and opportunities for improvement.
  • Prepares and delivers on time the reports required by the position, such as UR annual plan, Universes, Quality Indicators, SNP'S report, surveys, program descriptions, and corrective actions plans (as required) among others.
  • Responsible for conducting internal audits within UR Department.
  • Works in conjunction with all departments of the organization, including Quality for the development, implementation and monitoring of quality improvement programs.
  • Comply with FHC Compliance Department requests to assure internal and clients' compliance requirements.
  • Training and Development
  • Train UR staff and psychiatrists in the best practices, regulatory requirements, and documentation standards.
  • Provide ongoing education on evidence-based practices and updates in mental health treatment guidelines.
  • Identifies areas of development for the staff and coordinates the training needed to strengthen the performance of supervised employees.
  • Encourages the staff attendance and participation to the educational activities.
  • Communication
  • Demonstrates effective communication skills and reports to the VP of Clinical Affairs.
  • Maintains open communication with peers and the staff.
  • Keeps the staff informed about changes or situations related to department processes.
  • Meet with staff on a regular basis, one on one, and conduct monthly meetings or as needed.
  • Serve as the primary liaison with insurance companies, regulatory bodies, and other stakeholders regarding UM processes.
  • Communicate with patients and families about treatment options and the rationale for service denials, when appropriate.
  • Maintains effective interdependence processes and communication with the case management program and Access Center to work on organizational strategies and goals. Some examples are referral process and follow-up, analysis of the strategies to mitigate negative utilization trends such as, but not limited to, readmissions.
  • Demonstrates initiative in integration efforts across all levels of care and with other components of health care delivery system.
  • Works in collaboration with other departments of the organization.
  • Represents the organization in different activities and meetings.
  • Develop and Implement Policies
  • In conjunction with the VP of Clinical Affairs work with development and revision of departmental policies, program description, procedures, and annual plan.
  • Establish and update UR policies and procedures to optimize services and resource use.
  • Ensure staff adherence to protocols regarding case reviews, authorization processes, and members' assessments.
  • Effectively manages staff related matters in accordance with the rules, personnel policies and procedures.
  • Develops an annual vacation plan taking into consideration the service needs and the employees requests.
  • Keeps the specialization license and professional association membership ( colegiación ) effective as it corresponds to the specialization, if apply.
  • Meets with the mandatory trainings, such as: the Annual Compliance Plan, HR trainings, etc.

    • EEO Statement
    All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion, and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.
    Notice
    At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating highly efficient and best-in-class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449.
    Qualifications
      • Master's in social work, Psychology, Psychological Counseling, Mental Health Counseling or Psychiatric Nursing.
      • Unrestricted valid and current active license for Social Work, Psychiatric Nursing, Psychological Counseling, Psychology, or Mental Health Counseling in the relevant jurisdiction.
      • Professional associating membership ( colegiación ): Valid membership for Social Work and Psychiatric Nursing
      • A minimum of five years' experience in the mental health field, working directly with patients or in clinical services supervision. Three or more years of experience in a leadership role specifically in the utilization review area or in mental health case management field .
      • Require knowledge in Microsoft Office
      • Fully Bilingual

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    About Universal Health Services

    Sourced by ZipRecruiter

    Universal Health Services (UHS) is a major player in the healthcare industry, based in King of Prussia, Pennsylvania, U.S. Founded in 1978, UHS offers hospital and healthcare services. Their diverse services range from acute care hospitals, behavioral health facilities and ambulatory centers nationwide. The company's mission of enhancing the health and well-being of their patients is reflected in their commitment to 'Helping Individuals Live Longer, Healthier and Happier Lives'. Universal Health Services' consistent growth and success in their industry have been recognized on numerous occasions, including being ranked amongst the Fortune 500 list of largest companies.

    Industry

    Health care and social assistance

    Company size

    10,000+ Employees

    Headquarters location

    King of Prussia, PA, US

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