About the Company
UnitedHealthcare, a division of UnitedHealth Group, is a diversified health and well-being company dedicated to helping people live healthier lives and making the health system work better for everyone. We serve millions of individuals and provide a full spectrum of health benefit programs for individuals, employers, and Medicare and Medicaid beneficiaries, and we have a deep commitment to our communities. Join us in our mission to improve healthcare access and outcomes.
Job Description
We are seeking a dedicated and detail-oriented Utilization Review Nurse with an administrative focus to join our remote team. In this pivotal role, you will be responsible for reviewing medical necessity and appropriateness of care for various health services, ensuring compliance with established guidelines and policies. This position is 100% remote, offering flexibility while contributing significantly to patient outcomes and efficient healthcare resource utilization. Your administrative focus will involve extensive documentation, data entry, and communication with providers and internal teams, primarily through electronic systems and telephone. This role requires a strong clinical background combined with excellent organizational and administrative skills to manage a high volume of cases efficiently.
Key Responsibilities
- Perform comprehensive utilization review for pre-certification, concurrent, and retrospective cases based on medical necessity criteria and health plan policies.
- Apply clinical knowledge and established guidelines (e.g., InterQual, Milliman Care Guidelines) to determine appropriate levels of care and service authorizations.
- Document all review activities accurately and thoroughly in the electronic health record and other designated systems, ensuring compliance with regulatory requirements.
- Communicate review decisions to providers, members, and internal stakeholders in a clear, concise, and professional manner.
- Collaborate with physicians and other healthcare professionals to facilitate appropriate care plans and resolve any discrepancies or complex clinical issues.
- Identify and refer cases to medical directors for review when medical necessity is not met or when specific clinical expertise is required.
- Adhere to all regulatory requirements and company policies regarding privacy (HIPAA), compliance, and ethical standards.
- Participate in quality improvement initiatives and educational activities to maintain clinical competency and stay abreast of industry changes and best practices.
- Manage a high volume of cases efficiently while maintaining attention to detail and accuracy in a fast-paced remote environment.
Required Skills
- Current, unrestricted Registered Nurse (RN) license in at least one US state (multi-state licensure or willingness to obtain additional state licenses may be required).
- Minimum of 2 years of recent clinical experience in an acute care setting (e.g., medical-surgical, ICU, ER).
- Strong understanding of medical terminology, disease processes, and treatment modalities.
- Proficiency in applying utilization management criteria (e.g., InterQual, Milliman Care Guidelines).
- Excellent written and verbal communication skills for professional interactions.
- Proficient computer skills, including experience with electronic health records (EHR) and Microsoft Office Suite (Word, Excel, Outlook).
- Ability to work independently in a remote environment with strong organizational, time management, and problem-solving skills.
Preferred Qualifications
- Bachelor of Science in Nursing (BSN) degree.
- Certification in Utilization Management (e.g., CCM, ACM, CPHQ).
- Experience with managed care organizations or health insurance companies.
- Familiarity with remote work tools and platforms for effective virtual collaboration.
- Prior experience in a remote Utilization Review or Case Management role.
Perks & Benefits
- Comprehensive medical, dental, and vision insurance plans starting day one.
- Paid time off (PTO) and company-paid holidays.
- 401(k) retirement plan with competitive company match.
- Tuition reimbursement and continuing education opportunities for professional growth.
- Employee assistance program (EAP) for personal and professional support.
- Work-from-home stipend and essential equipment provided.
- Career development and growth opportunities within a leading global healthcare organization.
- Wellness programs and resources to support a healthy lifestyle.
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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