Remote Utilization Management RN: Path to CM

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

Vantagens oferecidas por esta oferta de emprego

Remote/Hybrid work

Bonus opportunities

401(k) match

Paid time off

Health coverage starts day 1

Leadership development programs

Resumo da oferta

WPS, a health solutions company, is seeking an Utilization Management RN to assess medical necessity, authorize services, and coordinate care with medical directors. The role offers remote work in multiple states and a potential path toward combined UM/CM responsibilities.

There is a strong emphasis on collaboration with Medical Directors, health plan colleagues, and cross-training in Case Management to support quality, cost-effective care.

Qualificações

• RN licensed in Wisconsin with current licensure.
• 4+ years of RN experience in varied clinical settings.
• 2+ years in Managed Care, 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.
• The ability to work independently, manage a case load, and prioritization.
• Excellent analytical, critical thinking, problem-solving skills and decision-making skills.
• Excellent communication and interpersonal skills to work with members, providers, and teams.
• Proficiency in Microsoft Office and healthcare software.

Responsabilidades

• Evaluate and determine medical necessity for services using evidence-based criteria.
• Authorize requested services and refer questionable cases to medical directors.
• Refer to CM/UM for future growth and cross-training opportunities.
• Collaborate with Medical Directors, Health Services, Sales, Claims and Billing teams.
• Document case summaries and manage cases that do not meet guidelines.
• Monitor Utilization Management queue to meet productivity standards.
• Analyze utilization trends and report findings to improve care and cost.
• Identify process improvement opportunities within the department.

Conhecimentos

RN licensure

Managed care

Case management

Analytical skills

Communication

Microsoft Office

Healthcare software

Formação académica

BSN

CCM certification

CM within health plan

URAC knowledge

CMCN certification

EMR systems experience

Ferramentas

EMR systems

Descrição da oferta de emprego

WPS, a health solutions company, is seeking an Utilization Management RN to assess medical necessity, authorize services, and coordinate care with medical directors. The role offers remote work in multiple states and a potential path toward combined UM/CM responsibilities.

There is a strong emphasis on collaboration with Medical Directors, health plan colleagues, and cross-training in Case Management to support quality, cost-effective care.