Remote Utilization Management RN — Impactful Care

SmartRecruiters, Inc.; Kenosha (WI); Remote; USD 70,000 - 75,000; Full time

Benefits offered by this job

Work from Home

Remote work

401(k) employer match

Life and Disability insurance

Paid time off

Job summary

Guidehealth is seeking a Utilization Management Registered Nurse (RN) for a fully remote, full-time role. You will apply medical necessity criteria to reviews and collaborate with medical directors and providers to ensure timely, compliant determinations.

The ideal candidate holds an active Illinois RN license, brings 3+ years of healthcare experience, and will integrate AI tools into daily workflows while maintaining regulatory compliance.

Qualifications

• Active Illinois RN license and unencumbered nursing practice.
• Three years of experience in diverse healthcare settings.
• Knowledge of utilization review, managed care, and URAC standards.
• CE requirements: 20 hours per 2-year cycle as mandated by Illinois.
• Strong organizational, writing, and communication skills.

Responsibilities

• Perform timely utilization reviews including precertification and concurrent reviews using criteria.
• Document clinical findings, criteria application, and determinations per standards.
• Communicate review outcomes to providers and members within set timeframes.
• Collaborate with Medical Director and peers on complex cases requiring review.
• Integrate AI tools into daily workflow and provide feedback for reliability.

Skills

Utilization review

Clinical documentation

Regulatory compliance

Communication with providers

AI in workflow

Education

RN license (IL)

Tools

AI integration

Job description

Guidehealth is seeking a Utilization Management Registered Nurse (RN) for a fully remote, full-time role. You will apply medical necessity criteria to reviews and collaborate with medical directors and providers to ensure timely, compliant determinations.

The ideal candidate holds an active Illinois RN license, brings 3+ years of healthcare experience, and will integrate AI tools into daily workflows while maintaining regulatory compliance.