Utilization Management RN

WPS—A health solutions company • Fitchburg, WI

2d • $75,000 - $100,000 • Remote

About The Position

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.

Requirements

• 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).
• 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.
• 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.
• High speed cable or fiber internet
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection

Nice To Haves

• Bachelor’s degree in nursing (BSN).
• Health insurance background in Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Supplement) 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.

Responsibilities

• Evaluate efficiency, appropriateness, and medical necessity for medical services, and procedures for our Health Plan.
• Use clinical knowledge to provide judgment to review medical services with evidence-based criteria, authorize requested services as appropriate.
• Refer questionable cases to medical directors to prevent unnecessary procedures, treatments, or prolonged hospital stays.

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level