Utilization Management Nurse RN - Per Diem - Remote

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.

Primary Responsibilities

• 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

Required Qualifications

• 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 Management or Utilization Review experience
• Experience supporting acute inpatient populations, concurrent review, or continued stay review
• Experience using InterQual, MCG/Milliman, or other evidence-based medical necessity criteria
• Experience with Medicare, Medicaid, commercial payer, managed care, authorization, or payer follow-up processes
• Experience working successfully in a remote or telecommuter role
• Denials management, denial prevention, or appeals support experience
• Proven ability to serve as a clinical resource to others and provide guidance on moderately complex issues

*All employees working remotely will be required to adhere to UnitedHealth Group's Telecommuter Policy

The hourly pay for this role will range from $29 - $52 per hour based on full-time employment.