Utilization Management Registered Nurse, RN

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

📋 Description

• Conduct timely utilization reviews of healthcare services, encompassing precertification and concurrent reviews, utilizing approved medical necessity criteria.

• Record clinical findings, criteria application, and decisions in accordance with regulatory and accreditation standards.

• Convey review decisions in writing and/or verbally to providers, members, and other necessary parties within defined timeframes.

• Collaborate with the Medical Director and Peer Reviewers on cases that require additional evaluation.

• Assess medical necessity, treatment plans, service intensity and duration for inpatient/outpatient care, and quality-of-care issues.

• Communicate effectively with ordering providers and provider organizations; engage with members or their representatives when appropriate.

• Incorporate Artificial Intelligence into daily operations and provide feedback for enhancing AI tools.

• Initiate referrals to disease management or population health initiatives.

• Participate in quality management and performance enhancement projects.

• Assist in the preparation of UM/PHM Committee materials and packets.

• Analyze cases that impact performance metrics and identify trends within assigned IPAs.

• Uphold confidentiality and compliance with federal and state regulations across various jurisdictions and medical groups.

• Implement medical group guidelines and URAC standards in daily review activities.

⛳️ Requirements

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

• Minimum of three years of experience in diverse healthcare environments.

• Understanding of utilization review, managed care, and community health concepts.

• Completion of 20 hours of continuing education every 2-year Illinois license renewal cycle.

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

• Strong organizational, writing, and verbal communication skills.

• Capacity to prioritize and respond to rapidly changing business needs.

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

• Ability to maintain strict confidentiality regarding member information and case documentation.

• Commitment to ongoing professional development in line with current nursing practice standards and the Illinois Nurse Practice Act.

• Reliable internet connection suitable for video calls and integration with internal/external systems.

• Minimum internet speed of 100 Mbps download and 10 Mbps upload.

• Availability during designated working hours.

• Openness to participate in virtual meetings with cameras on.

🏝️ Benefits

• Fully remote work providing flexibility and reduced commuting time.

• Comprehensive Medical, Dental, and Vision plans.

• 401(k) plan featuring a 3% employer match for up to a 6% employee contribution.

• Life and Disability insurance coverage.

• Options for Voluntary Life insurance.

• Employee Assistance Program (EAP) available.

• Paid time off benefits.

• Paid parental leave policy.

• Access to learning and development resources.

• Essential work equipment provided at no cost.

• Bi-weekly payroll schedule.