Remote Utilization Management RN — Data-Driven, Impactful Care

SmartRecruiters, Inc.; Gary (IN); Remote; USD 70,000 - 75,000; Full time

Benefits offered by this job

Work from home

Medical insurance

Dental & Vision

401(k) employer match

Life & Disability Insurance

Paid time off

Parental leave

Learning & development

Job summary

Guidehealth, a data-powered healthcare company, seeks a Utilization Management Registered Nurse (RN) to perform utilization review remotely. The role supports compliance with federal and state regulations and URAC standards, applying medical necessity criteria to documentation from medical records for determinations.

You will collaborate with the Medical Director and Peer Reviewers, communicate determinations to providers and members, and integrate AI into daily workflow while maintaining

Qualifications

• Active and unrestricted Illinois RN license.
• Minimum of 3 years in health care settings.
• Knowledge of utilization review processes and URAC standards.
• Experience with CE requirements for nursing licensure.
• Strong written and verbal communication skills.

Responsibilities

• Perform timely utilization reviews (precertification and concurrent) using approved medical necessity criteria.
• Document clinical findings and determinations per regulatory and accreditation standards.
• Communicate UR determinations to providers, members and required parties within established timeframes.
• Collaborate with Medical Director and Peer Reviewers on cases requiring further review of medical necessity, treatment plans, and care intensity/duration.
• Interface with ordering providers and provider organizations; inform members when appropriate.
• Integrate AI into daily workflow and provide feedback to improve AI reliability.

Skills

Active RN license (Illinois)

Utilization review

Managed care

Clinical documentation

Written & verbal comms

Job description

Guidehealth, a data-powered healthcare company, seeks a Utilization Management Registered Nurse (RN) to perform utilization review remotely. The role supports compliance with federal and state regulations and URAC standards, applying medical necessity criteria to documentation from medical records for determinations.

You will collaborate with the Medical Director and Peer Reviewers, communicate determinations to providers and members, and integrate AI into daily workflow while maintaining