Remote Utilization Management RN — Impact & Growth Path

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

Benefits offered by this job

Remote work options

Performance bonus/merit increase

401(k) with match

Competitive PTO

Health, dental, telehealth start day 1

Development programs

Job summary

WPS, a health solutions company, is seeking an Utilization Management RN to evaluate medical necessity and support appropriate care for members enrolled in our health plan. The role emphasizes evidence-based review, collaboration with medical directors, and opportunities to cross-train in Case Management with potential for a blended UM/CM position.

This position offers remote work options within approved states including Virginia, with competitive base salary of 75k to 100k and benefits.

Qualifications

• RN with current licensure (state unspecified in minimum) and clinical experience
• 4+ years as RN in varied settings
• 2+ years in Managed Care (prior authorization, utilization review)
• Experience managing and coordinating care for case-managed members
• Strong knowledge of medical practices, coding, and care trends
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits
• Independent, analytical, problem-solving, and strong communication skills; proficient in Office and healthcare software

Responsibilities

• Review medical necessity and authorize services per medical policies and evidence-based criteria
• Refer questionable cases to Medical Directors to prevent unnecessary procedures
• Cross-train in Case Management with potential growth into UM/CM
• Document case summaries and refer cases that do not meet guidelines to the Medical Director
• Monitor Utilization Management queue to meet productivity standards and report trends
• Collaborate with Health Services, Sales, Member Services, Claims, Provider Contracting, and Billing & Enrollment

Skills

RN licensure

Managed Care

Case coordination

Medical knowledge

Healthcare software

Microsoft Office

Communication

Education

BSN

CCM

CM within health plan

Tools

EMR systems

Microsoft Office

Job description

WPS, a health solutions company, is seeking an Utilization Management RN to evaluate medical necessity and support appropriate care for members enrolled in our health plan. The role emphasizes evidence-based review, collaboration with medical directors, and opportunities to cross-train in Case Management with potential for a blended UM/CM position.

This position offers remote work options within approved states including Virginia, with competitive base salary of 75k to 100k and benefits.