Remote UM RN — Path to Case Management

WPS Health Solutions; Charleston (SC); A distancia; USD 75.000 - 100.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote and hybrid work options

Performance bonus and merit increases

401(k) with full match on first 3%, 50

Competitive PTO

Health and dental insurance from DAY 1

Professional and LeadershipDevelopment

Know Your Rights and benefits link

Descripción de la vacante

WPS Health Solutions is seeking an experienced Utilization Management RN to evaluate efficiency, appropriateness, and medical necessity for health plan services. The role includes cross-training in Case Management with potential growth into a combined UM/CM position.

Start Date: 01/10/2027. Remote work options available in multiple states with a strong emphasis on quality care and cost-effective utilization. This position offers a competitive salary range and comprehensive benefits.

Formación

• RN licensed in Wisconsin; current licensure as RN.
• 4+ years RN experience in varied clinical settings.
• 2+ years in Managed Care (prior authorization, utilization review).
• Experience coordinating care for case managed members.
• Strong knowledge of medical practices, coding, care trends.
• Familiarity with health plan operations and insurance benefits.
• Independent work style with caseload management and prioritization.
• Proficient in MS Office and healthcare software.

Responsabilidades

• Evaluate medical necessity and appropriateness of services using evidence-based criteria.
• Refer questionable cases to medical directors to prevent unnecessary procedures.
• Cross-train in Case Management with potential growth into UM/CM roles.
• Review prior authorization requests for medical necessity and appropriateness.
• Collaborate with Medical Directors, Sales, Member Services, Claims, and Billing & Enrollment.
• Document case summaries and refer non-compliant cases to Medical Director.

Conocimientos

Nursing experience

Managed Care

Health plan knowledge

Analytical skills

Communication

MS Office

EMR software

CM knowledge

Educación

BSN

CCM certification

Certified Managerial Care Nurse (CMCN)

Herramientas

EMR systems

Managed care software

Descripción del empleo

WPS Health Solutions is seeking an experienced Utilization Management RN to evaluate efficiency, appropriateness, and medical necessity for health plan services. The role includes cross-training in Case Management with potential growth into a combined UM/CM position.

Start Date: 01/10/2027. Remote work options available in multiple states with a strong emphasis on quality care and cost-effective utilization. This position offers a competitive salary range and comprehensive benefits.