Remote Utilization Management RN - Path to CM

WPS—A health solutions company; Missouri; Teletrabalho; USD 75 000 - 100 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Remote and hybrid work options

Performance bonus

401(k) with match

Paid time off

Health, dental, telehealth

Leadership development

Resumo da oferta

WPS, a health solutions company, is seeking an Utilization Management RN to evaluate medical necessity and authorize services for our Health Plan. The role includes referring cases to medical directors and potential cross-training into Case Management, with growth toward a combined UM/CM position in the future.

The position offers remote work with approved states and a strong emphasis on quality care, cost control, and collaboration with Medical Directors and Health Services teams.

Qualificações

• RN with current licensure in the state of Wisconsin.
• 4+ years of RN experience in varied clinical settings.
• 2+ years of managed care experience (prior authorization, utilization review).
• Experience coordinating care for case managed members.
• Familiarity with URAC and health plan operations.

Responsabilidades

• Evaluate medical services for efficiency, appropriateness, and medical necessity.
• Refer questionable cases to medical directors to prevent unnecessary procedures.
• Cross-train in Case Management with potential for UM/CM growth.
• Document case summaries and monitor utilization queue to meet productivity standards.

Conhecimentos

RN

Managed care

Prior authorization

Analytical skills

Communication skills

Formação académica

BSN (preferred)

CCM (preferred)

Ferramentas

Microsoft Office

EMR systems

Descrição da oferta de emprego

WPS, a health solutions company, is seeking an Utilization Management RN to evaluate medical necessity and authorize services for our Health Plan. The role includes referring cases to medical directors and potential cross-training into Case Management, with growth toward a combined UM/CM position in the future.

The position offers remote work with approved states and a strong emphasis on quality care, cost control, and collaboration with Medical Directors and Health Services teams.