Remote Utilization Management RN - Health Plan

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

Benefits offered by this job

Remote work

Bonus program

401(k) match

Paid time off

Health insurance

Dental insurance

Telehealth

Development programs

Job summary

WPS, a health solutions company, seeks an Utilization Management RN to evaluate medical necessity and authorize services using evidence-based criteria. The role includes cross-training in Case Management with potential to grow into a combined UM/CM position or CM in the future.

Start date 01/10/2027; remote-friendly with approved states, including South Carolina. The RN must hold a Wisconsin license, have 4+ years of clinical RN experience and 2+ years in managed care, and be capable of

Qualifications

• RN with current licensure in the state of Wisconsin.
• 4+ years experience as an RN in varied clinical settings (hospital, clinic, home care, SNF).
• 2+ years experience in Managed Care (prior authorization, utilization review).
• Experience coordinating care for case managed members.
• Knowledge of medical practices, medical coding, and trends.

Responsibilities

• Evaluate efficiency, appropriateness, and medical necessity for medical services.
• Refer questionable cases to medical directors to prevent unnecessary procedures.
• Cross-train in Case Management with potential growth into UM/CM.
• Review prior authorization requests for medical necessity per policies.
• Document case summaries and refer cases not meeting guidelines to Medical Director.
• Monitor utilization queue to meet productivity standards.
• Collaborate with Health Services, Sales, Member Services, Claims, and Billing & Enrollment.

Skills

Analytical thinking

Critical thinking

Problem-solving

Decision-making

Communication

Interpersonal skills

Independent work

Caseload management

Education

Registered Nurse license (Wisconsin)

Tools

Microsoft Office

EMR systems

Job description

WPS, a health solutions company, seeks an Utilization Management RN to evaluate medical necessity and authorize services using evidence-based criteria. The role includes cross-training in Case Management with potential to grow into a combined UM/CM position or CM in the future.

Start date 01/10/2027; remote-friendly with approved states, including South Carolina. The RN must hold a Wisconsin license, have 4+ years of clinical RN experience and 2+ years in managed care, and be capable of