Utilization Management Nurse RN - Per Diem - Remote

Optum Insight is improving the flow of health data and information to create a more connected system. We remove friction and drive alignment between care providers and payers, and ultimately consumers. Our deep expertise in the industry and innovative technology empower us to help organizations reduce costs while improving risk management, quality and revenue growth. Ready to help us deliver results that improve lives? Join us to start Caring. Connecting. Growing together. The Utilization Management Nurse RN is responsible for performing utilization management activities to support appropriate use of healthcare services, compliance with established medical necessity criteria, and timely coordination across the care team and payer partners. The role supports admission reviews, concurrent reviews, continued stay reviews, authorization management, denial prevention, and appeals support when appropriate. This role is expected to operate with minimal guidance on most responsibilities, manage moderately complex work, assess needs, translate concepts into practice, and serve as a resource for others with less experience. You'll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Perform utilization review and medical necessity assessments for inpatient admissions and continued stays Conduct concurrent reviews using established clinical criteria and organizational guidelines Collaborate with physicians, case managers, social workers, and interdisciplinary partners to support patient care coordination and appropriate resource utilization Communicate with Medicare, Medicaid, commercial payers, and third-party reviewers regarding authorization and continued stay requirements Support denial prevention activities and assist with appeals processes when appropriate Apply InterQual, MCG/Milliman, or other evidence-based criteria to evaluate medical necessity Maintain compliance with CMS standards and applicable regulatory requirements Document utilization review activities and payer communications accurately and timely Independently manage assigned workload, prioritize competing demands, and escalate complex issues when needed Provide explanations, guidance, and support to team members on utilization management processes and moderately complex issues Skills and Capabilities: Demonstrated analytical, critical thinking, and problem-solving skills Effective verbal and written communication skills Ability to work independently with minimal guidance on routine and moderately complex responsibilities Ability to assess customer needs, identify solutions to non-standard requests, and translate concepts into practice Demonstrated organizational skills and ability to manage multiple priorities in a telecommuter environment You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Current, active, unrestricted Registered Nurse (RN) license in the state of Wisconsin (or Compact to include the state of Wisconsin) 3+ years of professional nursing experience Experience in utilization management, utilization review, case management, care coordination, medical necessity review, or a closely related clinical review function Experience evaluating clinical documentation and applying judgment to support appropriate care coordination or resource utilization Experience communicating with internal clinical stakeholders, payers, or external partners regarding care coordination, authorization, clinical documentation, or review outcomes Ability to work any of our per diem (as needed) shift schedules during our normal business hours (8am - 4:30pm), including flexibility to work both weekday and weekend shifts Preferred Qualifications: Bachelor of Science in Nursing (BSN) Utilization