PHRNs who are planning to take the NCLEX soon are also welcome to apply.
Join Optum and help make the health system work better for everyone. The US Registered Nurse reviews medical requests to make sure services are medically necessary and aligned with clinical guidelines. This role works closely with doctors, care teams, and insurance partners to support safe, appropriate, and cost‑effective patient care.
Role Overview:
You will conduct clinical coverage reviews for services requiring prior authorization. Using evidence‑based guidelines, medical policies, and benefit documentation, you will assess the medical necessity and appropriateness of both inpatient and outpatient services.
Your work helps members, providers, and care teams feel confident in the quality and integrity of our clinical decisions—giving you the opportunity every day to do your life's best work.
Key Responsibilities
- Review and assess medical requests for authorization (admissions, procedures, treatments)
- Apply clinical guidelines to determine medical necessity
- Coordinate with physicians, providers, and care teams for additional information when needed
- Document reviews and decisions accurately in the system
- Escalate complex cases to Medical Directors when required
- Ensure compliance with healthcare policies and turnaround times
- Collaborate with internal teams to support quality patient outcomes
Minimum qualifications:
- Valid and unrestricted USRN license
- PHRN license required; PHRNs planning to take the NCLEX soon are welcome to apply
- Minimum 2 years of hospital bedside experience, preferably in ICU, ER, Medical-Surgical, and/or Operating Room (OR)
- Strong clinical judgment and understanding of acute care and care coordination.
- Proficiency in computer navigation and electronic medical record review.
- Willing to work onsite during training and hybrid work arrangement post-training
Why Join Optum
- Be part of a global organization committed to innovation in health care.
- Work with diverse clinical teams in a supportive and collaborative environment.
- Grow your career with extensive learning and development opportunities.
- Experience meaningful work that directly impacts patient care outcomes.
What we Offer:
- Market Total Rewards Package
- 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
Who We are:
- 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.
- We're a diverse team with operations across North America, South America, Europe, Asia Pacific and the Middle East. This includes our over 25,000 employees in the Philippines.
- 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
