Utilization Management Registered Nurse, RN

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

📋 Description

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

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

• Gather, analyze, and precisely document clinical information from medical records.

• Record clinical findings, application of criteria, and determinations in alignment with regulatory and accreditation standards.

• Communicate review decisions to providers, members, and other necessary parties within established deadlines.

• Collaborate with Medical Directors and Peer Reviewers regarding medical necessity, treatment plans, service intensity and duration, as well as quality-of-care issues.

• Interact with ordering providers and provider organizations, and engage with members or their representatives as appropriate.

• Incorporate artificial intelligence into daily workflows and provide feedback to enhance AI tools.

• Initiate referrals to disease management or population health programs.

• Participate in quality management and performance improvement initiatives.

• Assist with UM/PHM Committee materials and packets, review cases impacting performance metrics, and identify trends within assigned IPAs.

• Safeguard the confidentiality of member information and case documentation.

• Ensure adherence to federal and state requirements across various jurisdictions and medical groups.

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

• Commit to ongoing professional growth and education in line with nursing practice standards and the Illinois Nurse Practice Act.

⛳️ Requirements

• Active and unrestricted Registered Nurse license in the state of Illinois.

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

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

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

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

• Strong organizational, writing, and speaking abilities.

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

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

• Interest in informatics.

• Knowledge in population health and health disparities.

• Previous experience in health insurance.

🏝️ Benefits

• Fully remote work arrangement.

• Medical, dental, and vision plans.

• 401(k) plan with a 3% employer match for your 6% contribution.

• Life and disability insurance.

• Options for voluntary life insurance.

• Employee Assistance Program (EAP).

• Paid time off plans.

• Paid parental leave.

• Resources for learning and development.

• Necessary work equipment provided at no cost.

• Flexible work location with an employee-provided internet connection.