Remote Inpatient Utilization Nurse, RN - Care Coordination

University of Minnesota School of Nursing; Sacramento (CA); Hybrid; USD 40,000 - 72,000; Full time

Benefits offered by this job

Benefits package

Incentive programs

Equity stock purchase

Job summary

Optum is seeking a Utilization Review Nurse, RN to manage inpatient utilization review and preauthorization requests. The role requires documentation of clinical reviews, applying medical necessity criteria, and coordinating with Medical Directors.

Remote options are available for eligible candidates. The position demands 3+ years of acute care nursing and 1+ year in Utilization Management, with knowledge of Medicare/Medicaid guidelines and InterQual or Milliman guidelines.

Qualifications

• Current unrestricted RN license in state of residence.
• Ability to obtain RN license in 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.
• Experience providing accurate and timely documentation of clinical review in care management systems.
• Proficient in Microsoft Word and Excel.

Responsibilities

• Maintains clinical expertise and knowledge of nursing progress and applies it to clinical review and care coordination.
• 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 care management system.
• Tracks utilization, variances and trends to support quality indicators.
• Prepares clinical information for case review with Physician Leadership.
• Identifies members for care coordination programs and collaborates with Medical Management.
• Completes Interrater Reliability Testing to ensure consistency of reviews.
• Meets timeliness standards for decisions, notifications and prior authorizations.
• Advocates for providers and patients with a courteous approach.
• Maintains confidentiality of patient and company information.
• Performs other duties to help department meet goals.

Skills

RN license

CA licensure within 90 days

3+ years acute care

1+ years Utilization Management

Medicare/Medicaid guidelines

Milliman/InterQual guidelines

care management documentation

analytical skills

MS Word & Excel

Pacific/Mountain Time residence

Job description

Optum is seeking a Utilization Review Nurse, RN to manage inpatient utilization review and preauthorization requests. The role requires documentation of clinical reviews, applying medical necessity criteria, and coordinating with Medical Directors.

Remote options are available for eligible candidates. The position demands 3+ years of acute care nursing and 1+ year in Utilization Management, with knowledge of Medicare/Medicaid guidelines and InterQual or Milliman guidelines.