Remote Utilization Management RN Path to CM

WPS Health Solutions; Marion (IL); A distancia; USD 75.000 - 100.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote and hybrid work options

Performance bonus and merit increase

401(k) with 100% match for first 3% of

Competitive PTO

Health, dental, and telehealth fromDay

Descripción de la vacante

WPS Health Solutions is seeking an Utilization Management RN to evaluate efficiency and medical necessity for health plan services. The role includes cross-training in Case Management with potential growth into CM.

Start date 01/10/2027. Remote work is available in multiple states, including Illinois and other listed states. Salary ranges from $75,000 to $100,000 with base pay variations based on experience.

Formación

• Registered Nurse (RN) with current licensure in the state of Wisconsin.
• 4+ years of experience as a Registered Nurse in varied clinical settings (hospital, clinic, home care, SNF, etc.).
• 2+ years of experience in Managed Care (prior authorization, utilization review), preferably within a commercial health plan.
• Demonstrated experience managing and coordinating care effectively for case managed members.
• Strong knowledge of current medical practices, medical coding, trends and patterns of care.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
• Ability to work independently, manage a caseload, and prioritize.
• Excellent analytical, critical thinking, problem-solving, and decision-making skills.
• Excellent communication and interpersonal skills to work with members, providers, and teams.
• Proficiency in Microsoft Office and healthcare software and systems.

Responsabilidades

• Evaluate efficiency, appropriateness, and medical necessity for services using evidence-based criteria.
• Authorize requested services as appropriate.
• Refer questionable cases to medical directors to prevent unnecessary procedures.
• Open to cross-training in Case Management with potential growth into UM/CM roles.
• Monitor and maintain Utilization Management queue to meet productivity standards.

Conocimientos

RN experience

Managed Care

Communication

Analytical thinking

Educación

Bachelor's degree in nursing (BSN)

Certified Case Manager (CCM)

URAC knowledge

Herramientas

Microsoft Office

Descripción del empleo

WPS Health Solutions is seeking an Utilization Management RN to evaluate efficiency and medical necessity for health plan services. The role includes cross-training in Case Management with potential growth into CM.

Start date 01/10/2027. Remote work is available in multiple states, including Illinois and other listed states. Salary ranges from $75,000 to $100,000 with base pay variations based on experience.