Remote Utilization Management RN - Health Plan Expert

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

Benefits offered by this job

Remote and hybrid work options

Performance bonus

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

Salary advancement opportunities

Job summary

WPS, a health solutions company, seeks an Utilization Management RN to evaluate medical necessity and service appropriateness for our Health Plan. You will authorize care, refer complex cases to medical directors, and may cross-train in Case Management with potential growth into CM roles.

Remote work is available in Colorado and other states; the position offers a competitive salary range, benefits, and opportunities to expand into combined UM/CM responsibilities over time.

Qualifications

• RN with current licensure in the state of Wisconsin.
• 4+ years as an RN in varied clinical settings (hospital, clinic, home care, SNF).
• 2+ years in Managed Care (prior authorization, utilization review) preferably in a commercial health plan.
• Experience managing and coordinating care for case managed members.
• Strong knowledge of medical practices, coding, and trends in care.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
• Independent work style with case load management, strong analytical and communication skills.

Responsibilities

• Evaluate efficiency, appropriateness, and medical necessity for medical services.
• Authorize services as appropriate and refer questionable cases to medical directors.
• Cross-train in Case Management with potential growth into UM/CM roles.
• Collaborate with Medical Directors and Health Services to facilitate decision-making.

Skills

RN experience

Managed Care

Case management

Medical coding knowledge

Health plan familiarity

MS Office & healthcare software

Education

Bachelor’s degree in nursing (BSN)

Tools

Microsoft Office

Healthcare software

Job description

WPS, a health solutions company, seeks an Utilization Management RN to evaluate medical necessity and service appropriateness for our Health Plan. You will authorize care, refer complex cases to medical directors, and may cross-train in Case Management with potential growth into CM roles.

Remote work is available in Colorado and other states; the position offers a competitive salary range, benefits, and opportunities to expand into combined UM/CM responsibilities over time.