Remote Inpatient Utilization Nurse (RN)

Sacbar; Sacramento (CA); Hybrid; USD 40,000 - 72,000; Full time

Job summary

Optum is seeking an experienced Utilization Review Nurse (RN) to perform inpatient utilization management and medical necessity determinations. You will review admissions and preauthorization requests, applying MCG/InterQual guidelines and contract terms to ensure cost-effective, high-quality patient care.

The role requires a current RN license, 3+ years of acute care/UM experience, and the ability to work in Pacific or Mountain Time Zones, with weekend requirements.

Qualifications

• Current unrestricted RN license in home state.
• Ability to obtain RN license in California within 90 days of hire.
• 3+ years of clinical nursing experience in acute care or LTAC.
• 1+ year of Utilization Management experience in hospital or insurance setting.
• Experience applying Medicare/Medicaid guidelines.
• Experience with Milliman (MCG) or InterQual guidelines.
• Experience preparing clinical information for case review with physician leadership.
• Experience documenting clinical reviews in care management systems.
• Analytical skills for quality case management and utilization review.
• Proficiency with Microsoft Word and Excel.
• Residence in Pacific or Mountain Time Zones; weekend/holiday hours required.

Responsibilities

• Maintains clinical expertise and applies evidence-based nursing principles in care coordination.
• Performs clinical reviews for appropriate utilization of medical services.
• Authorizes healthcare services per contracts and medical necessity criteria.
• Documents clinical reviews with rationale in care management system.
• Uses care management tools to analyze utilization, variances, and outcomes.
• Prepares clinical information for case review with Physician Leadership.
• Coordinates with care teams to support patient needs across the continuum.
• Completes Interrater Reliability testing to ensure consistent application of criteria.
• Meets timeliness standards for decisions, notifications, and pre-authorizations.
• Advocates for providers and patients; maintains confidentiality of information.
• Performs additional duties as required to meet department goals.

Skills

RN license

California license timeline

Clinical nursing experience

Utilization Management experience

Medicare/Medicaid guidelines

Milliman InterQual guidelines

Case review documentation

Analytical skills

Word & Excel

Time zone residence (Pacific/Mountain)

Weekend/Holiday hours

Tools

Care management system

Job description

Optum is seeking an experienced Utilization Review Nurse (RN) to perform inpatient utilization management and medical necessity determinations. You will review admissions and preauthorization requests, applying MCG/InterQual guidelines and contract terms to ensure cost-effective, high-quality patient care.

The role requires a current RN license, 3+ years of acute care/UM experience, and the ability to work in Pacific or Mountain Time Zones, with weekend requirements.