Utilization Management RN

WPS Health Solutions; Madison (WI); Remote; USD 75,000 - 100,000; Full time

Benefits offered by this job

Remote and hybrid work options

401(k) with matching

Health, dental, telehealth from day 1

Paid time off

Job summary

WPS Health Solutions in Madison, WI seeks an Utilization Management RN to evaluate medical necessity and authorize services using evidence-based criteria. The role collaborates with medical directors and may cross-train into Case Management, with potential to grow into a combined UM/CM position.

The position offers remote/hybrid options across approved states and a salary range of $75,000 to $100,000 with base pay dependent on experience. Start date is January 10, 2027.

Qualifications

• Registered Nurse (RN) with current licensure in Wisconsin.
• 4+ years as RN in varied clinical settings.
• 2+ years in Managed Care (prior authorization/utilization review), preferably in a commercial health plan.
• Experience managing and coordinating care for case managed members.
• Knowledge of current medical practices, coding, and care trends.
• Familiarity with health plan operations, payer/provider relationships, and benefits.

Responsibilities

• Evaluate efficiency, appropriateness, and medical necessity for medical services.
• Authorize requested services as appropriate.
• Refer questionable cases to medical directors to prevent unnecessary procedures.
• Cross-train in Case Management with potential growth to UM/CM.
• Document case summaries and refer non-conforming cases to Medical Directors.
• Monitor Utilization Management queue to meet productivity standards.
• Identify opportunities to improve department processes.

Skills

RN licensure

Managed care

Case coordination

Analytical skills

Communication skills

EMR systems

Education

BSN implied (Bachelor's in Nursing)

CCM preferred

Tools

Microsoft Office

EMR systems

Job description

Our Utilization Management RN (Registered Nurse) evaluates efficiency, appropriateness, and medical necessity for medical services, and procedures for our Health Plan. This role uses clinical knowledge to provide judgment to review medical services with evidence-based criteria, authorize requested services as appropriate. Our Utilization Management RN will be responsible for referring questionable cases to medical directors to prevent unnecessary procedures, treatments, or prolonged hospital stays. We're looking for someone who's open to cross-training in Case Management (CM), with the potential for the role to grow into a combined UM/CM position or transition into CM in the future.

Start Date: 01/10/2027

Salary Range: $75,000 ~ $100,000

The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

Work Location

We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin

How do I know this opportunity is right for me? If you:

• Enjoy working with healthcare professionals to facilitate appropriate and quality services in a cost-effective manner to positively impact medical loss ratio.
• Can work closely with Medical Directors to facilitate decision-making process for the Health Services department.
• Have experience reviewing medical and behavioral health prior authorization requests for medical necessity and appropriateness of requested treatment according to medical policies and evidence-based criteria.
• Have experience working closely with members of Health Services, and key contacts in Sales, Member Services, Claims, Provider Contracting, and Billing & Enrollment.
• Can document case summaries and refer cases to Medical Director that do not meet internal or external guidelines, policies, or medical criteria.
• Like to be accountable to monitor and maintain inventory in the Utilization Management queue to meet productivity standards.
• Enjoy evaluating, analyzing, and reporting trends in utilization changes in all healthcare delivery areas.
• Can make recommendations and implement changes consistent with Health Services objectives of quality care and reasonable cost.
• Would enjoy identifying opportunities and provide recommendations to improve department processes.
• Have Identified legal or liability issues and refer potential ethical or risk management issues to the appropriate department for resolution.
• Have participated in training new nursing staff on department workflows, policies, and procedures.
• Can work cross functionally to support other departmental efforts to ensure overall efficiency, quality productivity, and compliance with all departmental, regulatory and URAC standards.

Minimum Qualifications

• Registered Nurse (RN) with current licensure in the state of Wisconsin.
• 4 or more years of experience as a Registered Nurse in varied clinical settings (i.e., hospital, clinic, home care, skilled nursing facility, etc.).
• 2 or more years of experience in Managed Care (i.e., prior authorization, utilization review), preferably within a commercial health plan.
• Demonstrated experience managing and coordinating care effectively for case managed members.
• Strong knowledge of current medical practices, medical coding, trends and patterns of care.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
• Strong diverse experience and expertise that includes:
  • The ability to work independently, manage a case load, and prioritization.
  • Excellent analytical, critical thinking, problem-solving skills and decision-making skills.
  • Excellent communication and interpersonal skills to work with members, providers, and teams
  • Proficiency in Microsoft Office and healthcare software and systems.

Preferred Qualifications

• Bachelor's degree in nursing (BSN).
• Certified Case Manager (CCM) and prior experience in Case Management (CM) within a health plan.
• Background in commercial health insurance, including Point of Service (POS) or Preferred Provider Organization (PPO) plans.
• Knowledge of Utilization Review Accreditation Commission (URAC).
• Certified Managed Care Nurse (CMCN).
• Technical experience with word processing, spreadsheets, and proficiency with electronic medical record (EMR) systems and/or other managed care software.

Remote Work Requirements

• High speed cable or fiber internet
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)
• Please review Remote Worker FAQs for additional information

Benefits

• Remote and hybrid work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Professional and Leadership Development Programs
• Review additional benefits: (https://www.wpshealthsolutions.com/careers/)

Who We Are

WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.

Culture Drives Our Success

WPS' culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce-both current and future-to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

This employer is required to notify all applicants of their rights pursuant to federal employment laws.

For further information, please review the Know Your Rights notice from the Department of Labor.