Remote Utilization Management RN — Path to UM/CM

WPS Health Solutions; Omaha (NE); A distancia; USD 75.000 - 100.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

401(k) match

Health insurance

Dental insurance

Telehealth

Descripción de la vacante

WPS Health Solutions is seeking a Utilization Management Registered Nurse to evaluate medical necessity for services, coordinate care, and collaborate with Medical Directors. The role offers remote work within approved states and potential growth into Case Management.

Experience in managed care and strong analytical skills are required to drive quality and efficiency. The position emphasizes cross-training, adherence to policies, and supporting health services objectives while maintaining high

Formación

• RN licensed in Wisconsin.
• 4+ years RN experience in varied clinical settings.
• 2+ years in Managed Care, preferably within a commercial health plan.
• Experience coordinating care for case managed members.
• Strong knowledge of medical practices, coding, trends.

Responsabilidades

• Evaluate medical necessity for services using evidence-based criteria.
• Refer cases to Medical Directors when guidelines are not met.
• Collaborate with Medical Directors and Health Services team.
• Monitor utilization queue and productivity to meet targets.
• Support cross-training in Case Management and potential role growth.

Conocimientos

Care coordination

Analytical skills

Communication

Prior authorization

Educación

RN / BSN preferred

Licensed RN in Wisconsin

Herramientas

Microsoft Office

Descripción del empleo

WPS Health Solutions is seeking a Utilization Management Registered Nurse to evaluate medical necessity for services, coordinate care, and collaborate with Medical Directors. The role offers remote work within approved states and potential growth into Case Management.

Experience in managed care and strong analytical skills are required to drive quality and efficiency. The position emphasizes cross-training, adherence to policies, and supporting health services objectives while maintaining high