Remote Utilization Management RN — Impactful & Precise

Guidehealth; Northern (KY); Hybrid; USD 70,000 - 75,000; Full time

Benefits offered by this job

Work from Home

Health insurance

401(k) with match

Life and Disability insurance

Paid time off

Paid parental leave

EAP

Job summary

Guidehealth in the United States is seeking a qualified Utilization Management Registered Nurse (RN) for a remote, full-time role. You will perform utilization review activities and document determinations in compliance with URAC standards and federal/state regulations.

The ideal candidate holds an active Illinois RN license, has 3+ years' experience across health care settings, and can collaborate with providers and internal teams.

Qualifications

• Active and unrestricted Illinois RN license.
• Minimum of 3 years’ experience in various health care settings.
• Knowledge of utilization review, managed care, and population health.
• 20 hours of CE per 2-year license renewal cycle.
• Strong organizational, writing and verbal communication skills.
• Ability to prioritize and adapt to changing business needs.

Responsibilities

• Perform timely reviews of healthcare services, including precertification and concurrent reviews.
• Document clinical findings, criteria application, and determinations in accordance with standards.
• Communicate review determinations to providers and members within established timeframes.
• Collaborate with Medical Director and Peer Reviewers on cases requiring further review.
• Interface with ordering providers and provider organizations; communicate with members as appropriate.
• Integrate AI into daily workflow and provide feedback for reliability improvements.
• Initiate referrals to disease management or population health programs.
• Participate in quality management and performance improvement initiatives.
• Assist in UM/PHM committee materials and trend analysis.

Skills

Utilization review knowledge

Managed care

Community health understanding

Organizational skills

Written and verbal communication

Critical thinking

Education

Registered Nurse license (Illinois)

Job description

Guidehealth in the United States is seeking a qualified Utilization Management Registered Nurse (RN) for a remote, full-time role. You will perform utilization review activities and document determinations in compliance with URAC standards and federal/state regulations.

The ideal candidate holds an active Illinois RN license, has 3+ years' experience across health care settings, and can collaborate with providers and internal teams.