Remote Utilization Management RN – Growth to CM

WPS Health Solutions; Monona (WI); A distancia; USD 75.000 - 100.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote and hybrid work options

Descripción de la vacante

WPS Health Solutions is seeking an Utilization Management RN to evaluate medical necessity for services and procedures within our health plan. You will refer non-compliant cases to Medical Directors and may grow into a combined UM/CM role with cross-training in Case Management.

The role offers remote work in multiple states and a base salary range of $75,000 to $100,000. Start date is 01/10/2027, with opportunities for growth and professional development.

Formación

• RN licensed in Wisconsin.
• 4+ years RN experience in varied clinical settings.
• 2+ years in Managed Care, preferably within a commercial health plan.
• Experience managing and coordinating care for case managed members.
• Strong knowledge of current medical practices and coding.
• Familiarity with health plan operations and payer/provider relationships.

Responsabilidades

• Evaluate efficiency, appropriateness, and medical necessity for medical services.
• Refer questionable cases to medical directors to prevent unnecessary procedures.
• Open to cross-training in Case Management with potential growth into UM/CM.
• Document case summaries and refer cases not meeting guidelines to the Medical Director.
• Monitor inventory in the Utilization Management queue to meet productivity standards.
• Identify opportunities to improve department processes and efficiencies.

Conocimientos

RN licensure WI

RN experience

Managed care

Case management

Analytical skills

Communication skills

Microsoft Office

EMR systems

Independent work

Educación

BSN

CCM certification

CM within health plan

URAC knowledge

CMCN certification

Herramientas

Microsoft Office

EMR systems

Descripción del empleo

WPS Health Solutions is seeking an Utilization Management RN to evaluate medical necessity for services and procedures within our health plan. You will refer non-compliant cases to Medical Directors and may grow into a combined UM/CM role with cross-training in Case Management.

The role offers remote work in multiple states and a base salary range of $75,000 to $100,000. Start date is 01/10/2027, with opportunities for growth and professional development.