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Utilization Management Nurse RN

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 Utilization Management Nurse RN is responsible for performing utilization management activities to support appropriate use of healthcare services, compliance with established medical necessity criteria, and timely coordination across the care team and payer partners. The role supports admission reviews, concurrent reviews, continued stay reviews, authorization management, denial prevention, and appeals support when appropriate.

This role is expected to operate with minimal guidance on most responsibilities, manage moderately complex work, assess needs, translate concepts into practice, and serve as a resource for others with less experience.

You'll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

• Perform utilization review and medical necessity assessments for inpatient admissions and continued stays
• Conduct concurrent reviews using established clinical criteria and organizational guidelines
• Collaborate with physicians, case managers, social workers, and interdisciplinary partners to support patient care coordination and appropriate resource utilization
• Communicate with Medicare, Medicaid, commercial payers, and third-party reviewers regarding authorization and continued stay requirements
• Support denial prevention activities and assist with appeals processes when appropriate
• Apply InterQual, MCG/Milliman, or other evidence-based criteria to evaluate medical necessity
• Maintain compliance with CMS standards and applicable regulatory requirements
• Document utilization review activities and payer communications accurately and timely
• Independently manage assigned workload, prioritize competing demands, and escalate complex issues when needed
• Provide explanations, guidance, and support to team members on utilization management processes and moderately complex issues

Skills and Capabilities:

• Demonstrated analytical, critical thinking, and problem-solving skills
• Effective verbal and written communication skills
• Ability to work independently with minimal guidance on routine and moderately complex responsibilities
• Ability to assess customer needs, identify solutions to non-standard requests, and translate concepts into practice
• Demonstrated organizational skills and ability to manage multiple priorities in a telecommuter environment

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:

• Current, active, unrestricted Registered Nurse (RN) license in the state of Wisconsin (or Compact to include the state of Wisconsin)
• 3+ years of professional nursing experience
• Experience in utilization management, utilization review, case management, care coordination, medical necessity review, or a closely related clinical review function
• Experience evaluating clinical documentation and applying judgment to support appropriate care coordination or resource utilization
• Experience communicating with internal clinical stakeholders, payers, or external partners regarding care coordination, authorization, clinical documentation, or review outcomes
• Ability to work any of our per diem (as needed) shift schedules during our normal business hours (8am - 4:30pm), including flexibility to work both weekday and weekend shifts

Preferred Qualifications:

• Bachelor of Science in Nursing (BSN)
• Utilization Management or Utilization Review experience
• Experience supporting acute inpatient populations, concurrent review, or continued stay review
• Experience using InterQual, MCG/Milliman, or other evidence-based medical necessity criteria
• Experience with Medicare, Medicaid, commercial payer, managed care, authorization, or payer follow-up processes
• Experience working successfully in a remote or telecommuter role
• Denials management, denial prevention, or appeals support experience
• Proven ability to serve as a clinical resource to others and provide guidance on moderately complex issues

*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 hourly pay for this role will range from $29 - $52 per hour 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 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.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.