Remote Utilization Management RN — Path to UM/CM

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

Vantagens oferecidas por esta oferta de emprego

Remote and hybrid work options

Performance bonus

401(k) match

Paid time off

Health insurance

Dental insurance

Telehealth services

Professional development

Resumo da oferta

WPS—A health solutions company is seeking an Utilization Management RN who evaluates efficiency, appropriateness, and medical necessity for services within our Health Plan. This role collaborates with Medical Directors and Health Services to authorize appropriate care and refer cases that do not meet criteria.

Remote work is allowed for specified states, with potential growth into combined UM/CM roles. A strong background in managed care and case coordination is required.

Qualificações

• RN with current licensure in the state of Wisconsin.
• 4+ years of nursing experience in varied clinical settings.
• 2+ years in Managed Care (prior authorization, utilization review).
• Experience coordinating care for case managed members.
• Knowledge of medical practices, medical coding, and care trends.
• Familiarity with health plan operations, payer/provider relationships, and benefits.
• Ability to work independently, manage a caseload, and prioritize.
• Excellent communication and analytical skills.

Responsabilidades

• Evaluate efficiency, appropriateness, and medical necessity for services.
• Refer questionable cases to medical directors to prevent unnecessary procedures.
• Cross-train in Case Management with potential growth to UM/CM roles.
• Monitor utilization queue and maintain productivity standards.
• Collaborate with Medical Directors and Health Services teams on decision-making.
• Document case summaries and refer cases not meeting guidelines to appropriate parties.

Conhecimentos

Analytical skills

Critical thinking

Problem solving

Decision making

Communication

Interpersonal skills

Microsoft Office

Healthcare software

Formação académica

Bachelor’s degree in nursing (BSN)

Ferramentas

EMR systems

Healthcare software

Microsoft Office

Descrição da oferta de emprego

WPS—A health solutions company is seeking an Utilization Management RN who evaluates efficiency, appropriateness, and medical necessity for services within our Health Plan. This role collaborates with Medical Directors and Health Services to authorize appropriate care and refer cases that do not meet criteria.

Remote work is allowed for specified states, with potential growth into combined UM/CM roles. A strong background in managed care and case coordination is required.