RN - Remote Inpatient Utilization Management

Palo Verde Community College District; Sacramento (CA); Hybrid; USD 60,000 - 108,000; Full time

Job summary

Optum is seeking an experienced Utilization Review Nurse (RN) to support inpatient care management in a remote-capable role. You will review admissions and preauthorizations using evidence-based criteria and collaborate with Medical Directors.

The position requires an active RN license, California licensing within 90 days, 3+ years in acute care and 1+ year in Utilization Management, plus proficiency in Word and Excel.

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+ year 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 in care management systems.
• Experience employing analytical skills for quality case management, utilization review, and quality improvement.
• Proficiency with MS Word and Excel.
• Primary residence in Pacific or Mountain Time Zones and weekend/holiday hours.

Responsibilities

• Maintains clinical expertise and knowledge of nursing progress and applies it to care coordination.
• Performs clinical review for appropriate utilization of medical services using medical necessity criteria.
• Authorizes healthcare services per contracts, guidelines, and medical necessity criteria.
• Documents clinical reviews with rationale in the care management system.
• Uses care management tools to track utilization, variances, and outcomes.
• Prepares clinical information for case reviews with Physician Leadership for patient treatment and care planning.
• Identifies members for care coordination programs and collaborates with Medical Management.
• Completes Interrater Reliability Testing to ensure consistency of review.
• Meets timeliness standards for decision, notification, and prior authorization activities.
• Serves as advocate for providers and patients.
• Maintains confidentiality of all company procedures and patient information.
• Performs other duties to help the department achieve goals.

Skills

RN license

CA license

Clinical nursing

Utilization mgmt

Medicare/Medicaid guidelines

Milliman InterQual

Documentation

Analytical skills

MS Word Excel

Pacific/Mountain TZ

Job description

Optum is seeking an experienced Utilization Review Nurse (RN) to support inpatient care management in a remote-capable role. You will review admissions and preauthorizations using evidence-based criteria and collaborate with Medical Directors.

The position requires an active RN license, California licensing within 90 days, 3+ years in acute care and 1+ year in Utilization Management, plus proficiency in Word and Excel.