PHRN - Utilization Review Nurse or Case Management | Work from Home | Day 1 HMO!

ROLE AND RESPONSIBILITIES

• Review and interpret Medicaid policies and healthcare guidelines
• Translate complex requirements into logical workflows and decision pathways
• Conduct research to clarify ambiguous or detailed policy content
• Participate in peer reviews and quality checks to ensure accuracy
• Finalize and document outputs for system implementation

• Independent work (70–80%) focused on analysis, research, and logic-building
• Collaborative work (20–30%) through team discussions and knowledge sharing
• Use of standard tools such as MS Word, Excel, PDF, and SharePoint
• Non-patient-facing and non-customer-facing role (back-end healthcare operations)

• Must be a Registered Nurse (RN) with an active license
• With solid clinical and hospital experience
• Minimum of 3 years’ experience in a BPO setting, handling US Healthcare accounts
• Preferred experience in any of the following areas:
• Utilization Management
• Medical Coding
• Prior Authorization
• Case Management
• Strong communication skills (both verbal and written)
• Demonstrated critical thinking, analytical, and problem-solving abilities
• Comfortable working with complex documents, clinical guidelines, and policies
• Experience using the InterQual tool is an advantage
• Highly detail-oriented with strong learning agility
• Willing to work on Eastern or Central US time zones
• Must be amenable to a Work-from-Home setup (Equipment provided by the company)

• Market Competitive Pay Levels
• Retirement Plan
• Medical Plan (HMO) from Day 1 of employment
• Dental, Medical, and Optical Reimbursements
• Life and Disability Insurance
• Paid Time-Off Benefits
• Sick Leave Conversion
• Tuition Fee Reimbursement
• Employee Assistance Program (EAP)
• Annual Performance Based Merit Increases
• Employee Recognition
• Training and Staff Development
• Employee Referral Program
• Employee Volunteerism Opportunity
• All Mandatory Statutory Benefits

• Optum is the health care technology and innovation company of the UnitedHealth Group enterprise along with UnitedHealthcare.
• UnitedHealth Group is a health care and well-being company with a mission to help people live healthier lives and help make the health system work better for everyone.
• We’re a leading health solution and care delivery organization. Our work is complex, but our mission is simple: create a healthier world, with you at the center.
• As part of a Fortune 5 enterprise, we are improving the health care experience of over 125 million people around the world.
• Elevate your career with a leading health care company while improving lives.

Join us in evolving health care so everyone can have the opportunity to live their healthiest life. This is your opportunity to be part of a team that’s dedicated to Caring. Connecting. Growing together