Remote Utilization Management RN — Path to CM

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

Vantagens oferecidas por esta oferta de emprego

Remote and hybrid work options

Performance bonus/merit increase

401(k) match (3% + 2% partial)

Generous paid time off

Health and dental insurance from day 1

Resumo da oferta

WPS Health Solutions is seeking a Utilization Management Registered Nurse to evaluate efficiency, appropriateness, and medical necessity of medical services for our Health Plan. This role may cross-train in Case Management with potential growth into a combined UM/CM position.

The position offers remote work options in multiple states, including Texas, with a salary range of $75,000 to $100,000. Start date is 01/10/2027, and base pay varies by knowledge and experience.

Qualificações

• RN with current licensure in Wisconsin.
• 4+ years as a Registered Nurse in varied clinical settings.
• 2+ years in Managed Care (prior authorization, utilization review).
• Experience coordinating and managing care for CM/case managed members.
• Knowledge of medical practices, coding, and trends in care.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
• Ability to work independently, manage a case load, and prioritize tasks.
• Excellent analytical, problem-solving, and communication skills.
• Proficiency with healthcare software and systems (EMR, etc.).

Responsabilidades

• Evaluate medical necessity and appropriateness of services using evidence-based criteria.
• Refer questionable cases to Medical Directors to prevent unnecessary procedures or hospital stays.
• Potential to cross-train in Case Management with growth into UM/CM roles.
• Collaborate with Health Services, Sales, Member Services, Claims, Provider Contracting, and Billing & Enrollment.
• Document case summaries and refer cases not meeting guidelines to Medical Directors.

Conhecimentos

Analytical thinking

Strong communication

Independent work

Case management

Formação académica

Bachelor’s degree in nursing (BSN)

Ferramentas

Microsoft Office

EMR systems

Descrição da oferta de emprego

WPS Health Solutions is seeking a Utilization Management Registered Nurse to evaluate efficiency, appropriateness, and medical necessity of medical services for our Health Plan. This role may cross-train in Case Management with potential growth into a combined UM/CM position.

The position offers remote work options in multiple states, including Texas, with a salary range of $75,000 to $100,000. Start date is 01/10/2027, and base pay varies by knowledge and experience.