Inpatient Utilization Review RN - Remote (PST/MST)

NHSHP; Sacramento (CA); Hybrid; USD 39,950,000 - 71,635,000; Full time

Job summary

Optum is seeking a Utilization Review Nurse, RN to perform inpatient utilization management, applying evidence-based guidelines and medical necessity criteria. The role involves day-to-day clinical reviews, documentation, and collaboration with Medical Leadership across Pacific/Mountain time zones.

The ideal candidate has 3+ years in clinical nursing, 1+ year in Utilization Management, and familiarity with Medicare/Medicaid guidelines, MCg/InterQual, and care coordination processes.

Qualifications

• Current unrestricted Registered Nurse (RN) license in state of residence.
• Ability to obtain Registered Nurse license in the state of California within 90 days of hire.
• 3+ years of clinical nursing experience in acute care hospital or LTAC setting.
• 1+ years of Utilization Management experience in hospital or insurance setting.
• Experience applying Medicare and/or Medicaid guidelines.
• Experience with Milliman (MCG) or InterQual guidelines.
• Experience researching and preparing clinical information for case review with Physician Leadership for patient treatment and care planning.
• Experience providing accurate and timely documentation of clinical review and supporting rationale of decision in care management systems.
• Experience employing analytical skills necessary for quality case management, utilization review, and quality improvement to meet organizational objectives.
• Experience using Microsoft Word and Excel.

Responsibilities

• Maintains clinical expertise and knowledge of current nursing practice and guidelines.
• Performs clinical review for appropriate utilization of medical services using medical necessity criteria.
• Authorizes healthcare services in compliance with contracts and guidelines.
• Documents clinical reviews with rationale in the care management system.
• Tracks and analyzes utilization, variances, outcomes and quality indicators.
• Prepares clinical information for case review with Physician Leadership.

Skills

RN license

Utilization management

Clinical nursing

Tools

MS Word

Excel

Job description

Optum is seeking a Utilization Review Nurse, RN to perform inpatient utilization management, applying evidence-based guidelines and medical necessity criteria. The role involves day-to-day clinical reviews, documentation, and collaboration with Medical Leadership across Pacific/Mountain time zones.

The ideal candidate has 3+ years in clinical nursing, 1+ year in Utilization Management, and familiarity with Medicare/Medicaid guidelines, MCg/InterQual, and care coordination processes.