Remote Utilization Management RN — Path to CM

WPS Health Solutions; Jacksonville (FL); Teletrabalho; USD 75 000 - 100 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Remote work

Bonus

401(k) match

Paid time off

Health insurance

Development programs

Resumo da oferta

WPS Health Solutions is seeking an Utilization Management RN to evaluate medical necessity and authorize services for our Health Plan. This role involves clinical judgment, collaboration with Medical Directors, and potential cross-training in Case Management.

The position offers remote/hybrid options across multiple states with growth opportunities toward a combined UM/CM role in the future.

Qualificações

• RN licensed in Wisconsin with 4+ years in varied clinical settings.
• 2+ years in Managed Care (prior authorization/utilization review).
• Knowledge of medical practices, coding, and care trends.
• Familiarity with health plan operations, payer relationships, and benefits.
• Excellent communication, analytical, and problem-solving skills.

Responsabilidades

• Evaluate efficiency, appropriateness, and medical necessity of services and procedures.
• Authorize requested services per evidence-based criteria.
• Refer questionable cases to Medical Directors to prevent unnecessary procedures.
• Cross-train in Case Management with potential growth into UM/CM.
• Monitor Utilization Management queue to meet productivity standards and report trends.

Conhecimentos

RN experience

Managed Care

Case Management

Healthcare software

Formação académica

BSN

Ferramentas

Microsoft Office

Descrição da oferta de emprego

WPS Health Solutions is seeking an Utilization Management RN to evaluate medical necessity and authorize services for our Health Plan. This role involves clinical judgment, collaboration with Medical Directors, and potential cross-training in Case Management.

The position offers remote/hybrid options across multiple states with growth opportunities toward a combined UM/CM role in the future.