About the Company
Optum, a part of UnitedHealth Group, is a leading health services innovation company dedicated to helping people live healthier lives and making the health system work better for everyone. We combine technology, data, and expertise to improve the delivery, quality, and efficiency of health care. Our commitment to innovation and patient-centered care drives us to seek out talented individuals who are passionate about making a difference.
Job Description
We are seeking a highly motivated and detail-oriented Utilization Review Nurse with an administrative focus to join our remote team. In this 100% remote role, you will play a crucial part in ensuring the appropriate utilization of healthcare services by reviewing medical records against established criteria. This position requires strong critical thinking, excellent communication skills, and the ability to work independently in a fast-paced environment. Your administrative focus will involve extensive documentation, data entry, and collaboration with a multidisciplinary team to facilitate optimal patient outcomes and resource management.
Key Responsibilities
- Conduct comprehensive medical record reviews for inpatient, outpatient, and ancillary services to determine medical necessity and appropriateness of care based on established criteria (e.g., InterQual, Milliman Care Guidelines).
- Document all review findings accurately and thoroughly in the designated system, ensuring compliance with regulatory and company standards.
- Communicate professionally and effectively with providers, care managers, and other healthcare professionals regarding review outcomes and alternative care suggestions.
- Identify and refer cases that do not meet criteria to a Physician Reviewer or Medical Director for further review.
- Participate in interdisciplinary team meetings to discuss complex cases and contribute to care planning.
- Maintain up-to-date knowledge of clinical guidelines, healthcare regulations, and payer policies.
- Assist in the development and refinement of utilization review processes and administrative workflows.
- Handle sensitive patient information with the utmost confidentiality and adherence to HIPAA regulations.
- Manage a caseload efficiently, prioritizing tasks to meet deadlines and productivity targets.
Required Skills
- Current, unrestricted Registered Nurse (RN) license in the state of California.
- Minimum of 3 years of recent clinical nursing experience.
- Strong understanding of medical terminology, disease processes, and healthcare delivery systems.
- Proficiency in using electronic medical records (EMR) and other healthcare IT systems.
- Excellent written and verbal communication skills.
- Exceptional organizational and time management abilities.
- Demonstrated critical thinking and problem-solving skills.
- Ability to work independently and as part of a remote team.
- Proficiency with Microsoft Office Suite (Word, Excel, Outlook).
Preferred Qualifications
- Bachelor of Science in Nursing (BSN).
- 1+ year of experience in Utilization Review, Case Management, or Quality Assurance.
- Certification in Utilization Review (e.g., CCMC, CMGT-UR).
- Experience with InterQual or Milliman Care Guidelines (MCG).
- Previous experience in a remote work environment.
Perks & Benefits
- Comprehensive health, dental, and vision insurance.
- Generous paid time off and holidays.
- 401(k) retirement plan with company match.
- Life and disability insurance.
- Tuition reimbursement and professional development opportunities.
- Employee assistance program.
- Wellness programs and resources.
- Work-from-home stipend for equipment and internet.
How to Apply
If you are interested in this position, please click the "Apply Now" button below. To ensure your application is properly considered, please prepare the following:
- An up-to-date Resume or CV
- A brief cover letter summarizing your experience and motivation
Applications are reviewed on a rolling basis. Only shortlisted candidates will be contacted for an interview.
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