RN Utilization Management Specialist | Case & Care

Jobtailor; Menasha (WI); On-site; USD 70,000 - 100,000; Full time

Job summary

Network Health is seeking a skilled Registered Nurse for Utilization Management. The role focuses on prior authorization, education of care teams, and comprehensive care assessments from pre- through post-service stages.

The ideal candidate holds an RN license in Wisconsin with a BSN preferred and at least four years of clinical health care experience, including exposure to managed care and utilization management. This is a remote, full-time position with standard business hours.

Qualifications

• Associate Degree in Nursing is required.
• Current RN licensure in Wisconsin is required.
• Bachelor of Science in Nursing is preferred.
• Minimum of four years of clinical health care experience as an RN.
• Experience in insurance, managed care, and utilization management is preferred.
• Reliable internet required for home office work and candidates must reside in Wisconsin.
• Ability to work 40 hours per week, 8am–5pm Monday through Friday.

Responsibilities

• Evaluate and process prior authorization requests and referrals.
• Follow Network Health policies for authorization review (pre-service, concurrent, post-service).
• Verify eligibility and benefits and document utilization management communications.
• Educate members, caregivers, providers, and staff about utilization management activities.
• Participate in Utilization Management auditing and denial file review.
• Refer complex cases to Case Management.
• Complete holistic care management assessments.
• Collaborate with other departments to develop interdepartmental processes.
• Support Utilization Management programs and goals.
• Screen candidates for Case Management intervention and determine appropriate level of care.
• Complete assessments and plans of care including medications and treatment plans.

Skills

Prior Authorization

Eligibility Verification

Care Management

Auditing

Cost Reduction

Collaboration

Education

Communication

Education

Associate Degree in Nursing

Bachelor of Science in Nursing

Job description

Network Health is seeking a skilled Registered Nurse for Utilization Management. The role focuses on prior authorization, education of care teams, and comprehensive care assessments from pre- through post-service stages.

The ideal candidate holds an RN license in Wisconsin with a BSN preferred and at least four years of clinical health care experience, including exposure to managed care and utilization management. This is a remote, full-time position with standard business hours.