Inpatient Utilization RN: Impactful Care & Coordination

Texas Health Institute; Sacramento, Northern (CA, KY); Hybrid; USD 40,000 - 72,000; Full time

Job summary

Optum is seeking a Utilization Review Nurse (RN) to perform inpatient utilization management, applying evidence-based guidelines to determine medical necessity for admissions and preauthorizations. The role requires strong clinical judgment, documentation in care management systems, and collaboration with physician leadership.

Remote work is available for those in PST/MST with weekend hours; CA licensure within 90 days is required and experience with Medicare/Medicaid guidelines is preferred.

Qualifications

• Current unrestricted RN license required.
• Ability to obtain CA RN license within 90 days of hire.
• Minimum 3 years clinical nursing in acute care or LTAC.
• 1+ year Utilization Management experience in hospital or insurance.
• Experience applying Medicare/Medicaid guidelines.
• Experience with Milliman (MCG) or InterQual guidelines.
• Experience documenting clinical reviews in care management systems.
• Strong analytical skills for quality case management and utilization review.
• Proficiency in MS Word and Excel.
• Primary residence in Pacific or Mountain Time Zones; weekend/holiday hours required.

Responsibilities

• Review inpatient criteria for acute hospital admissions and preauthorization requests using evidence-based guidelines.
• Authorize healthcare services in accordance with contracts and plan guidelines.
• Document clinical reviews with rationales in the care management system.
• Track utilization, variances, and outcomes to support quality indicators.
• Prepare case information for physician leadership review and care planning.
• Collaborate with Medical Management for care coordination across the continuum of care.
• Maintain confidentiality of patient and company information.
• Perform other duties to help the department achieve goals.

Skills

RN license

California licensure in 90 days

3+ years clinical nursing

1+ year Utilization Management

Medicare/Medicaid guidelines

Milliman MC G / InterQual guidelines

care management documentation

analytical skills

MS Word & Excel

Pacific/Mountain Time Zone residence

Education

Nursing degree (RN)

Tools

Milliman MC G guidelines

InterQual guidelines

Care management software

Job description

Optum is seeking a Utilization Review Nurse (RN) to perform inpatient utilization management, applying evidence-based guidelines to determine medical necessity for admissions and preauthorizations. The role requires strong clinical judgment, documentation in care management systems, and collaboration with physician leadership.

Remote work is available for those in PST/MST with weekend hours; CA licensure within 90 days is required and experience with Medicare/Medicaid guidelines is preferred.