Utilization Management Registered Nurse, RN

Job not on LinkedIn

🔥 12 hours ago

🇮🇳 India – Remote

💵 $70k - $75k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 11%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Guide Healthcare

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2018

⚕️ Healthcare Insurance

🏥 Healthcare

🎯 Recruiter

Healthcare Insurance • Healthcare • Recruitment

Guide Healthcare is leading a movement where creativity delivers positive change in the healthcare sector. The company specializes in allied health service provision and healthcare recruitment, focusing on the support and treatment of older adults. With a commitment to adding value to their clients, partners, and teams, Guide Healthcare aims to do things differently in the industry.

📋 Description

• Perform timely utilization reviews of healthcare services, including precertification and concurrent reviews, using approved medical necessity criteria • Document clinical findings, criteria application, and determinations according to regulatory and accreditation standards • Communicate review determinations in writing and/or verbally to providers, members, and other required parties within established timeframes • Collaborate with the Medical Director and Peer Reviewers on cases requiring further review • Review medical necessity, treatment plans, inpatient/outpatient service intensity and duration, and quality-of-care concerns • Interface with ordering providers and provider organizations; communicate with members or representatives when appropriate • Integrate Artificial Intelligence into daily workflow and provide feedback to improve AI tools • Initiate referrals to disease management or population health programs • Participate in quality management and performance improvement initiatives • Assist in developing UM/PHM Committee materials and packets • Review cases affecting performance metrics and identify trends within assigned IPAs • Maintain confidentiality and compliance with federal and state regulations across jurisdictions and medical groups • Apply medical group guidelines and URAC standards to daily review activities

🎯 Requirements

• Registered Nurse with an active and unrestricted Illinois State License • Three years of experience in a variety of health care settings • Knowledge of utilization review, managed care, and community health • Completion of 20 hours of continuing education per 2-year Illinois license renewal cycle • Computer skills including Microsoft 365 (Word, Excel, PowerPoint, etc.) • Strong organizational, writing, and speaking skills • Ability to prioritize and react to rapidly changing business needs • Excellent clinical judgment, compassion, and a positive attitude • Ability to maintain strict confidentiality of member information and case documentation • Ongoing professional growth and education consistent with current nursing practice standards and the Illinois Nurse Practice Act • Own internet connection capable of video calls and internal/external systems • Minimum internet speed of 100 Mbps download and 10 Mbps upload • Ability to be accessible during stated working hours • Willingness to join virtual meetings with cameras on

🏖️ Benefits

• Fully remote work with flexibility and reduced commuting • Medical, Dental, and Vision plans • 401(k) plan with a 3% employer match to a 6% employee contribution • Life and Disability insurance • Voluntary Life insurance options • Employee Assistance Program (EAP) • Paid time off plans • Paid parental leave • Learning and development resources • Necessary work equipment provided at no charge • Bi-weekly payroll