Remote Utilization Management RN — Path to CM Growth

WPS Health Solutions; Kansas City (MO); Teletrabalho; USD 75 000 - 100 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Remote and hybrid options

401(k) with match

Health/dental insurance from Day 1

Paid time off

Professional development

Resumo da oferta

WPS Health Solutions seeks an experienced Utilization Management Registered Nurse (UM RN) to evaluate efficiency, appropriateness, and medical necessity for medical services under our Health Plan. The role includes cross-training in Case Management with potential growth into a combined UM/CM position and future CM opportunities.

The candidate will collaborate with Medical Directors, Health Services teams, and other departments while reviewing prior authorization requests and ensuring alignment

Qualificações

• Registered Nurse with current Wisconsin license.
• 4+ years of RN experience in varied clinical settings.
• 2+ years in Managed Care, preferably within a commercial health plan.
• Experience reviewing medical necessity and prior authorization requests.
• Familiarity with health plan operations and payer/provider relationships.
• Ability to work independently and manage a caseload.

Responsabilidades

• Evaluate efficiency, appropriateness, and medical necessity for medical services.
• Authorize services as appropriate and refer questionable cases to medical directors.
• Cross-train in Case Management with potential growth to UM/CM.
• Collaborate with health services teams and various departments.
• Document case summaries and monitor utilization trends.

Conhecimentos

Analytical thinking

Communication skills

Problem-solving

Decision making

Independent work

Formação académica

RN licensure in Wisconsin

BSN preferred

Ferramentas

EMR systems

Microsoft Office

Descrição da oferta de emprego

WPS Health Solutions seeks an experienced Utilization Management Registered Nurse (UM RN) to evaluate efficiency, appropriateness, and medical necessity for medical services under our Health Plan. The role includes cross-training in Case Management with potential growth into a combined UM/CM position and future CM opportunities.

The candidate will collaborate with Medical Directors, Health Services teams, and other departments while reviewing prior authorization requests and ensuring alignment