Remote Utilization Management RN: Grow into CM

WPS—A health solutions company; Indiana; Remote; USD 75,000 - 100,000; Full time

Benefits offered by this job

Remote and hybrid work options

Performance bonus

401(k) with matching

Paid time off

Health, dental, telehealth start Day 1

Professional development programs

Careers site

Job summary

WPS Health Solutions seeks a Utilization Management RN to evaluate medical necessity and authorize appropriate services for our Health Plan. The role offers cross-training in Case Management with potential growth into a combined UM/CM position. Start Date: 01/10/2027.

Remote work is available in numerous states, including Indiana. Wisconsin RN licensure is required, with further CM/UM responsibilities and collaboration with Medical Directors to ensure quality care and cost effectiveness.

Qualifications

• RN with Wisconsin license
• 4+ years of RN experience in varied clinical settings
• 2+ years in Managed Care (prior authorization/utilization review)
• Experience coordinating care for CM/uM
• Knowledge of medical practices and coding
• Familiarity with health plan operations and payer/provider relationships
• Independent work style with ability to manage a caseload
• Strong analytical, problem-solving and communication skills

Responsibilities

• Evaluate efficiency, appropriateness, and medical necessity for medical services using evidence-based criteria.
• Refer questionable cases to medical directors to prevent unnecessary procedures or hospital stays.
• Cross-train in Case Management with potential growth into a combined UM/CM role.
• Review medical and behavioral health prior authorizations for medical necessity and appropriateness.
• Collaborate with Health Services teams, Sales, Member Services, Claims, Provider Contracting, and Billing & Enrollment.

Skills

Case management

Managed care

Communication

Analytical thinking

Office software

Education

BSN preferred

RN license Wisconsin

Tools

EMR systems

Microsoft Office

Job description

WPS Health Solutions seeks a Utilization Management RN to evaluate medical necessity and authorize appropriate services for our Health Plan. The role offers cross-training in Case Management with potential growth into a combined UM/CM position. Start Date: 01/10/2027.

Remote work is available in numerous states, including Indiana. Wisconsin RN licensure is required, with further CM/UM responsibilities and collaboration with Medical Directors to ensure quality care and cost effectiveness.