Remote Utilization Management RN — Drive Quality & Cost Efficiency

WPS Health Solutions; Denver (CO); Remote; USD 75,000 - 100,000; Full time

Benefits offered by this job

Remote and hybrid work options

Performance bonus and merit increase

401(k) with 100% match for first 3% of

of your salary and 50% match for next

Job summary

The Utilization Management RN position at WPS Health Solutions evaluates medical necessity and appropriateness of services for our Health Plan, applying evidence-based criteria to authorize care. The role collaborates with medical directors to review questionable cases and supports cross-training toward Case Management to grow into a combined UM/CM position.

We offer a remote-friendly work arrangement with multiple states allowed, a competitive salary, and comprehensive benefits.

Qualifications

• Registered Nurse (RN) with current licensure in Wisconsin.
• 4+ years of experience as a Registered Nurse in varied clinical settings.
• 2+ years of experience in Managed Care, preferably within a commercial health plan.
• Demonstrated experience coordinating care for case-managed members.
• Strong knowledge of medical practices, coding, and care trends.
• Familiarity with health plan operations and insurance benefits.

Responsibilities

• Review medical necessity and prior authorization requests for medical necessity and appropriateness.
• Coordinate care effectively for case-managed members.
• Collaborate with Medical Directors to facilitate decision-making.
• Document case summaries and refer when criteria are not met.
• Maintain Utilization Management queue productivity and reporting.

Skills

Independent work

Analytical skills

Communication

MS Office

Education

BSN

CCM certification

Tools

EMR systems

Healthcare software

Job description

The Utilization Management RN position at WPS Health Solutions evaluates medical necessity and appropriateness of services for our Health Plan, applying evidence-based criteria to authorize care. The role collaborates with medical directors to review questionable cases and supports cross-training toward Case Management to grow into a combined UM/CM position.

We offer a remote-friendly work arrangement with multiple states allowed, a competitive salary, and comprehensive benefits.