Remote Utilization Management RN — Path to UM/CM

WPS Health Solutions; Newark (NJ); A distancia; USD 75.000 - 100.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote/hybrid work options

Performance bonus

401(k) match

Paid time off

Health insurance

Dental insurance

Telehealth services

Leadership development

Descripción de la vacante

WPS Health Solutions seeks an Utilization Management RN to evaluate medical necessity and appropriateness of services for our health plan. This role uses clinical knowledge to review requests, authorize care when appropriate, and refer cases to medical directors to avoid unnecessary procedures and extended hospital stays.

We support remote work in multiple states and offer opportunities to grow into a combined UM/CM role.

Formación

• RN license for practice in Wisconsin and clinical nursing experience across settings.
• BSN preferred; advanced nursing certification valued.
• CCM and CM credentials preferred for health-plan experience.
• Familiarity with URAC accreditation and managed care principles.
• Proficiency with EMR systems and standard healthcare software.
• Strong analytical and decision-making abilities to manage caseloads.

Responsabilidades

• Evaluate efficiency, appropriateness, and medical necessity of services for the health plan.
• Authorize services when appropriate and refer questionable cases to medical directors.
• Document case summaries and communicate recommendations to care teams.
• Support cross-training in Case Management with potential growth into UM/CM roles.
• Collaborate with Medical Directors, Sales, Member Services, Claims, and other departments.

Conocimientos

Analytical thinking

Critical thinking

Communication

Case management coordination

Prior authorization

Microsoft Office proficiency

Educación

RN license Wisconsin

BSN

CCM certification

CM within health plan

URAC knowledge

CMCN certification

Herramientas

EMR systems

Descripción del empleo

WPS Health Solutions seeks an Utilization Management RN to evaluate medical necessity and appropriateness of services for our health plan. This role uses clinical knowledge to review requests, authorize care when appropriate, and refer cases to medical directors to avoid unnecessary procedures and extended hospital stays.

We support remote work in multiple states and offer opportunities to grow into a combined UM/CM role.