Remote Utilization Management RN — Review & Optimize Care

WPS—A health solutions company; Madison (WI); A distancia; USD 75.000 - 100.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote and hybrid work options

Performance bonus and/or merit

401(k) with match

Competitive PTO

Health insurance from Day 1

Professional and Leadership Dev

Descripción de la vacante

WPS is seeking an Utilization Management RN to evaluate medical necessity for services and authorize appropriate care. You will reference evidence-based criteria and may refer questionable cases to medical directors to prevent unnecessary procedures.

There is potential to cross-train in Case Management with growth into UM/CM roles. The position offers collaboration with Medical Directors and Health Services, documentation of case summaries, and remote work options in approved states.

Formación

• RN licensed in Wisconsin and 4+ years in varied clinical settings.
• 2+ years in Managed Care, preferably within a commercial health plan.
• Experience managing and coordinating care for case managed members.
• Strong knowledge of medical practices, medical coding, trends and patterns of care.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
• Independent work, prioritization, analytical thinking, and strong communication skills.

Responsabilidades

• Evaluate efficiency, appropriateness, and medical necessity for services using evidence-based criteria.
• Refer questionable cases to medical directors to prevent unnecessary procedures.
• Cross-train in Case Management with potential growth into UM/CM or CM roles.
• Collaborate with Medical Directors and Health Services to support decision-making and care coordination.
• Document case summaries and refer cases not meeting guidelines toMedical Director.

Conocimientos

Independent worker

Analytical thinking

Communication

MS Office

Educación

Bachelor’s degree in nursing (BSN)

Certified Case Manager (CCM)

Certified Managed Care Nurse (CMCN)

Herramientas

EMR systems

Healthcare software

Descripción del empleo

WPS is seeking an Utilization Management RN to evaluate medical necessity for services and authorize appropriate care. You will reference evidence-based criteria and may refer questionable cases to medical directors to prevent unnecessary procedures.

There is potential to cross-train in Case Management with growth into UM/CM roles. The position offers collaboration with Medical Directors and Health Services, documentation of case summaries, and remote work options in approved states.