Utilization Management Nurse RN - Remote

UnitedHealth Group•Miami, FL

12h•Remote

About The Position

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 Clinical Utilization Management Nurse is responsible for performing utilization review activities 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. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges.

Requirements

Active, unrestricted RN or LPN license in the state of residency
3+ years of experience in utilization review or case management in an acute care setting
Solid knowledge of InterQual/MCG criteria, CMS regulations, and payer guidelines
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, Cerner Powerchart
Familiarity with healthcare payer operations

Responsibilities

Conduct timely and accurate 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.
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
Support education efforts by sharing updates on documentation standards and regulatory requirements with clinical teams
Contribute to quality and compliance initiatives as directed by leadership
Maintain accurate records of reviews, authorizations, and outcomes for reporting purposes
Advocate for patients to ensure appropriate care while balancing resource utilization