Utilization Management Registered Nurse, RN

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

📋 Description

• Conduct timely utilization reviews of healthcare services, including precertification and concurrent assessments.

• Utilize approved medical necessity criteria to evaluate clinical information from medical records.

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

• Relay review decisions to providers, members, and other relevant parties within set timeframes.

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

• Engage with ordering providers and provider organizations.

• Communicate with members or their representatives when appropriate.

• Incorporate AI into daily operations and provide insights to enhance AI tools.

• Initiate referrals to disease management or population health programs.

• Participate in quality management and performance enhancement initiatives.

• Assist with UM/PHM Committee materials and packets.

• Analyze cases impacting performance metrics and identify trends within designated IPAs.

• Uphold the confidentiality of member information and case documentation.

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

• Apply medical group guidelines and URAC standards in review processes.

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

⛳️ 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.

• Completion of 20 hours of continuing education every 2 years for Illinois license renewal.

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

• Strong organizational, writing, and verbal communication skills.

• Ability to prioritize and adapt to rapidly changing business demands.

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

• Interest in Informatics.

• Knowledge of Population Health and Disparities.

• Previous experience in health insurance.

• Reliable internet connection with a minimum of 100 Mbps download and 10 Mbps upload speeds.

• Availability during designated working hours.

• Compliance with security policies and procedures to protect PHI, PII, and Guidehealth intellectual property.

🏝️ Benefits

• Fully remote work arrangement.

• Necessary work equipment provided at no cost.

• Medical, Dental, and Vision plans.

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

• Life and Disability insurance.

• Voluntary Life options available.

• Employee Assistance Program (EAP).

• Paid time off plans.

• Paid parental leave.

• Resources for learning and development.