Remote Utilization Management RN - Path to Case Management

WPS Health Solutions; Madison (WI); Remote; USD 75,000 - 100,000; Full time

Benefits offered by this job

Remote and hybrid work options

401(k) with matching

Health, dental, telehealth from day 1

Paid time off

Job summary

WPS Health Solutions in Madison, WI seeks an Utilization Management RN to evaluate medical necessity and authorize services using evidence-based criteria. The role collaborates with medical directors and may cross-train into Case Management, with potential to grow into a combined UM/CM position.

The position offers remote/hybrid options across approved states and a salary range of $75,000 to $100,000 with base pay dependent on experience. Start date is January 10, 2027.

Qualifications

• Registered Nurse (RN) with current licensure in Wisconsin.
• 4+ years as RN in varied clinical settings.
• 2+ years in Managed Care (prior authorization/utilization review), preferably in a commercial health plan.
• Experience managing and coordinating care for case managed members.
• Knowledge of current medical practices, coding, and care trends.
• Familiarity with health plan operations, payer/provider relationships, and benefits.

Responsibilities

• Evaluate efficiency, appropriateness, and medical necessity for medical services.
• Authorize requested services as appropriate.
• Refer questionable cases to medical directors to prevent unnecessary procedures.
• Cross-train in Case Management with potential growth to UM/CM.
• Document case summaries and refer non-conforming cases to Medical Directors.
• Monitor Utilization Management queue to meet productivity standards.
• Identify opportunities to improve department processes.

Skills

RN licensure

Managed care

Case coordination

Analytical skills

Communication skills

EMR systems

Education

BSN implied (Bachelor's in Nursing)

CCM preferred

Tools

Microsoft Office

EMR systems

Job description

WPS Health Solutions in Madison, WI seeks an Utilization Management RN to evaluate medical necessity and authorize services using evidence-based criteria. The role collaborates with medical directors and may cross-train into Case Management, with potential to grow into a combined UM/CM position.

The position offers remote/hybrid options across approved states and a salary range of $75,000 to $100,000 with base pay dependent on experience. Start date is January 10, 2027.