Utilization Management Registered Nurse, RN

This is a fully remote position, open to applicants in Illinois.

📋 Description

• Conducting utilization review activities in alignment with federal and state regulations, URAC standards, and Guidehealth policies.

• Utilizing established medical necessity criteria to gather, assess, and accurately record clinical information from medical records to support utilization decisions.

• Collaborating with providers, medical directors, and internal teams to ensure prompt, compliant, and high-quality review processes.

• Executing timely evaluations of healthcare services, including precertification and concurrent reviews, utilizing approved medical necessity criteria.

• Precisely documenting clinical findings, application of criteria, and determinations in accordance with regulatory and accreditation standards.

• Communicating review determinations (both written and verbal) to providers, members, and other necessary parties within set timeframes.

• Partnering with the Medical Director and Peer Reviewer(s) on cases that necessitate further examination of medical necessity and treatment plans.

• Initiating referrals for identified patients to disease management or population health programs to ensure continuity and quality of care.

⛳️ Requirements

• Active and unrestricted Illinois State License as a Registered Nurse.

• Minimum of three years of experience across various healthcare settings.

• Familiarity with utilization review, managed care, and community health.

• The State of Illinois mandates Nursing Professional Staff to complete 20 hours of continuing education every 2-year license renewal cycle.

• Proficient computer skills, including Microsoft 365 (Word, Excel, PowerPoint, etc.).

• Strong organizational, writing, and verbal communication skills are essential.

• Ability to prioritize and adapt according to rapidly changing business needs.

• Exceptional clinical judgment, compassion, and a positive demeanor.

🏝️ Benefits

• Work from Home: Guidehealth operates as a fully remote company, allowing you to minimize commuting time and concentrate on your professional objectives and personal requirements.

• Keep Health a Priority: We provide comprehensive Medical, Dental, and Vision plans to ensure you are well covered.

• Plan for the Future: Our 401(k) plan features a 3% employer match on your 6% contribution.

• Have Peace of Mind: We offer Life and Disability insurance for those unexpected moments.

• Additionally, we provide voluntary Life options to safeguard you and your loved ones.

• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is available to assist you during challenging times.

• Take Time for Yourself: We offer paid time off plans to help you achieve a work-life balance and fulfill your personal aspirations.

• Support Your New Family: Guidehealth provides paid parental leave to grant you the time you need.

• Learn and Grow: Your professional development is a priority for us. Guidehealth offers various resources dedicated to your learning and advancement within the company.