Remote Utilization Management RN — Clinical Review Leader

Guidehealth; Chicago (IL); Remote; USD 70,000 - 75,000; Full time

Benefits offered by this job

Work from Home

Medical, Dental, Vision plans

401(k) with 3% match

Life and Disability insurance

Employee Assistance Program (EAP)

Paid time off

Parental leave

Learning and development

Job summary

Guidehealth is seeking a Utilization Management Registered Nurse (RN) for a fully remote, full-time position. The role involves applying medical necessity criteria to reviews, documenting findings, and interfacing with providers and members to ensure timely, compliant determinations.

Illinois license active and 3+ years clinical experience preferred. Responsibilities include collaboration with Medical Director, AI workflow integration, and participation in quality initiatives.

Qualifications

• Registered Nurse with an active and unrestricted Illinois State License.
• Three years of experience in a variety of health care settings.
• Knowledge of utilization review, managed care, and community health.
• Illinois CE requirement: 20 hours per 2-year license renewal cycle.
• Strong organizational, writing, and speaking skills.

Responsibilities

• Perform utilization reviews (precert, concurrent) using approved criteria.
• Document clinical findings and determinations per regulatory standards.
• Communicate review determinations to providers, members, and required parties within timeframes.
• Collaborate with Medical Director and Peer Reviewers on cases needing further review of medical necessity.

Skills

RN license

Utilization review

Healthcare experience

Analytical thinking

Job description

Guidehealth is seeking a Utilization Management Registered Nurse (RN) for a fully remote, full-time position. The role involves applying medical necessity criteria to reviews, documenting findings, and interfacing with providers and members to ensure timely, compliant determinations.

Illinois license active and 3+ years clinical experience preferred. Responsibilities include collaboration with Medical Director, AI workflow integration, and participation in quality initiatives.