Utilization Management RN

WPS—A health solutions company • Fitchburg, WI

2d • $75,000 - $100,000 • Remote

About The Position

The Utilization Management RN evaluates the efficiency, appropriateness, and medical necessity of medical services and procedures for the Health Plan. Using clinical knowledge and evidence-based criteria, this nurse reviews and authorizes requested services as appropriate, and refers questionable cases to medical directors to help prevent unnecessary procedures, treatments, or prolonged hospital stays. The role is open to cross-training in Case Management, with the possibility of growing into a combined UM/CM role or transitioning into Case Management in the future.

The position works with healthcare professionals and Medical Directors to support quality, cost-effective care and decision-making for the Health Services department. It collaborates with Health Services colleagues and contacts in Sales, Member Services, Claims, Provider Contracting, and Billing & Enrollment. The RN maintains the Utilization Management queue, analyzes utilization trends, recommends improvements to care and departmental processes, and supports compliance with departmental, regulatory, and URAC standards.

The role may be performed remotely from approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, or Wisconsin. Remote workers must have high-speed cable or fiber internet with at least 10 Mbps downstream and 1 Mbps upstream.

Requirements

• Current Registered Nurse (RN) license in the state of Wisconsin.
• At least 4 years of Registered Nurse experience in varied clinical settings, such as hospitals, clinics, home care, or skilled nursing facilities.
• At least 2 years of Managed Care experience, such as prior authorization or utilization review; experience within a commercial health plan is preferred in the minimum qualifications.
• Demonstrated experience managing and coordinating care effectively for case-managed members.
• Strong knowledge of current medical practices, medical coding, and trends and patterns of care.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
• Ability to work independently, manage a caseload, and prioritize work.
• Strong analytical, critical-thinking, problem-solving, and decision-making skills.
• Excellent communication and interpersonal skills for working with members, providers, and teams.
• Proficiency with Microsoft Office and healthcare software and systems.
• For remote work: high-speed cable or fiber internet with at least 10 Mbps downstream and 1 Mbps upstream.

Nice To Haves

• Bachelor’s degree in nursing (BSN).
• Certified Case Manager (CCM) credential and prior Case Management experience 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) credential.
• Technical experience with word processing, spreadsheets, electronic medical record (EMR) systems, and/or other managed care software.

Responsibilities

• Review medical and behavioral health prior authorization requests for medical necessity and appropriateness using medical policies and evidence-based criteria.
• Authorize requested services as appropriate and refer cases that do not meet internal or external guidelines, policies, or medical criteria to a Medical Director.
• Prepare and document case summaries and work with Medical Directors to facilitate decision-making.
• Collaborate with healthcare professionals and contacts across Health Services, Sales, Member Services, Claims, Provider Contracting, and Billing & Enrollment.
• Manage and coordinate care effectively for case-managed members.
• Monitor and maintain the Utilization Management queue inventory to meet productivity standards.
• Evaluate, analyze, and report utilization trends across healthcare delivery areas.
• Recommend and implement changes that support quality care and reasonable cost in line with Health Services objectives.
• Identify opportunities to improve department processes and provide recommendations.
• Identify legal or liability issues and refer potential ethical or risk management issues to the appropriate department.
• Participate in training new nursing staff on department workflows, policies, and procedures.
• Work cross-functionally to support departmental efficiency, quality, productivity, and compliance with departmental, regulatory, and URAC standards.
• Be open to cross-training in Case Management.

Benefits

• Remote and hybrid work options.
• Performance bonus and/or merit increase opportunities.
• 401(k) with a 100% match for the first 3% of salary and a 50% match for the next 2%; immediately 100% vested.
• Competitive paid time off.
• Health insurance, dental insurance, and telehealth services starting on day one.
• Professional and Leadership Development Programs.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed