Clinical Utilization Management Nurse - Per Diem

UnitedHealth Group•Madison, WI

3d•$28 - $50•Hybrid

About The Position

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together. The Clinical Utilization Management Nurse (PRN) is responsible for performing utilization review activities on an as-needed basis to ensure appropriate use of medical resources, compliance with regulatory requirements, and adherence to clinical best practices. This role supports acute hospital utilization management, helps prevent payer denials, and contributes to maintaining revenue integrity. The nurse collaborates with physicians, case managers, and interdisciplinary teams to promote efficient, high-quality patient care.

Requirements

High School Diploma/GED (or higher)
Active, unrestricted RN license in the state of Wisconsin
3+ years of experience in utilization review or case management in an acute care setting
3+ years of experience with InterQual/MCG criteria, CMS regulations, and payer guidelines
Intermediate level of proficiency in electronic medical records and utilization management software

Nice To Haves

Certification in Utilization Management or Case Management (e.g., ACM, CCM)
Experience with Epic EMR
Familiarity with healthcare payer operations

Responsibilities

Perform admission, concurrent, and discharge reviews to determine medical necessity and appropriate level of care
Apply InterQual/MCG criteria and payer guidelines to support clinical decisions
Communicate with physicians and care teams to address documentation gaps and ensure compliance with CMS and commercial payer requirements
Assist in peer-to-peer review coordination by gathering necessary documentation for payer discussions
Document utilization review findings in electronic medical records and utilization management systems
Participate in interdisciplinary rounds and collaborate on discharge planning to reduce avoidable days and length of stay
Monitor and escalate potential or actual payer denials for timely resolution
Perform documentation audits to ensure completeness and accuracy related to utilization criteria
Stay current on regulatory and payer policy updates and apply them in daily reviews
Maintain accurate records of reviews, authorizations, and outcomes for reporting purposes
Advocate for patients to ensure appropriate care while balancing resource utilization