Remote Utilization Management RN: Growth toward CM

WPS Health Solutions; Hampton (VA); Teletrabalho; USD 75 000 - 100 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Remote and hybrid work options

Performance bonus

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

401(k) with a 50% match for the next 2

Health insurance start Day 1

Dental insurance

Professional development opportunities

Resumo da oferta

WPS Health Solutions seeks an Utilization Management RN to evaluate efficiency, appropriateness, and medical necessity for medical services within our Health Plan. The RN will apply clinical knowledge to review services with evidence-based criteria and authorize care as appropriate, with referrals to medical directors for questionable cases.

We offer remote work in numerous states and opportunities to cross-train in Case Management, with potential growth into a combined UM/CM role in the future.

Qualificações

• Registered Nurse (RN) with current licensure in the state of Wisconsin.
• 4 or more years of experience as a Registered Nurse in varied clinical settings (hospital, clinic, home care, SNF).
• 2 or more years of experience in Managed Care (prior authorization, utilization review), preferably within a commercial health plan.
• Demonstrated experience managing and coordinating care effectively for case managed members.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.

Responsabilidades

• Evaluate efficiency, appropriateness, and medical necessity for medical services with evidence-based criteria.
• Authorize requested services as appropriate and refer questionable cases to medical directors.
• Cross-train in Case Management with potential growth into a combined UM/CM role.

Conhecimentos

Managed Care experience

Clinical judgment

Analytical skills

Communication skills

Interdepartmental collaboration

Prior authorization

Formação académica

BSN preferred

Ferramentas

EMR systems

Microsoft Office

Descrição da oferta de emprego

WPS Health Solutions seeks an Utilization Management RN to evaluate efficiency, appropriateness, and medical necessity for medical services within our Health Plan. The RN will apply clinical knowledge to review services with evidence-based criteria and authorize care as appropriate, with referrals to medical directors for questionable cases.

We offer remote work in numerous states and opportunities to cross-train in Case Management, with potential growth into a combined UM/CM role in the future.