Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.  

The Clinical Utilization Management Nurse is responsible for performing utilization review activities to ensure appropriate use of medical resources, compliance with regulatory requirements, and adherence to clinical best practices. This role supports acute hospital utilization management, helps prevent payer denials, and contributes to maintaining revenue integrity. The nurse collaborates with physicians, case managers, and interdisciplinary teams to promote efficient, high-quality patient care.

Primary Responsibilities:

• Conduct timely and accurate admission, concurrent, and discharge reviews to determine medical necessity and appropriate level of care
• Apply InterQual/MCG criteria and payer guidelines to support clinical decisions
• Communicate with physicians and care teams to address documentation gaps and ensure compliance with CMS and commercial payer requirements
• Assist in peer-to-peer review coordination by gathering necessary documentation for payer discussions
• Document utilization review findings in electronic medical records and utilization management systems
• Participate in interdisciplinary rounds and collaborate on discharge planning to reduce avoidable days and length of stay
• Monitor and escalate potential or actual payer denials for timely resolution
• Perform documentation audits to ensure completeness and accuracy related to utilization criteria
• Stay current on regulatory and payer policy updates and apply them in daily reviews
• Support education efforts by sharing updates on documentation standards and regulatory requirements with clinical teams
• Contribute to quality and compliance initiatives as directed by leadership
• Maintain accurate records of reviews, authorizations, and outcomes for reporting purposes
• Advocate for patients to ensure appropriate care while balancing resource utilization
• Ability work occasional evening or weekend hours to meet operational needs

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.

Required Qualifications:

• Active, unrestricted RN license in the state of Wisconsin
• 3+ years of experience in utilization review or case management in an acute care setting
• Proven solid knowledge of InterQual/MCG criteria, CMS regulations, and payer guidelines
• Proficiency in electronic medical records and utilization management software

• Reside in the Waukesha, WI regional area and be able to work onsite daily

   

Preferred Qualifications:

• Certification in Utilization Management or Case Management (e.g., ACM, CCM)
• Experience with Epic EMR
• Demonstrated familiarity with healthcare payer operation
• Ability to work in a fast-paced clinical environment with frequent collaboration across departments

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $58,800 to $105,000 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.  

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.