Utilization Management Registered Nurse, RN

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🔥 14 minutes ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $70k - $75k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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

• Performing utilization review activities in compliance with federal and state regulations, URAC standards, and Guidehealth policies. • Applying established medical necessity criteria to obtain, analyze, and accurately document clinical information from medical records in support of utilization determinations. • Working collaboratively with providers, medical directors, and internal teams to ensure timely, compliant, and high-quality review processes. • Performing timely reviews of healthcare services, including precertification and concurrent reviews, using approved medical necessity criteria. • Accurately documenting clinical findings, criteria application, and determinations in accordance with regulatory and accreditation standards. • Communicating review determinations (written and/or verbal) to providers, members, and other required parties within established timeframes. • Collaborating with the Medical Director and Peer Reviewer(s) on cases requiring further review of medical necessity and treatment plans. • Initiating referrals of identified patients to disease management or population health programs to support continuity and quality of care.

🎯 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. • The State of Illinois requires Nursing Professional Staff to complete 20 hours of CE per 2-year license renewal cycle. • Computer skills including Microsoft 365 (Word, Excel, PowerPoint, etc). • Strong organizational, writing, and speaking skills are necessary. • Ability to prioritize and react based on rapidly changing business needs. • Excellent clinical judgment, compassion, and a positive attitude.

🏖️ Benefits

• Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs. • Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered. • Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution. • Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. • Additionally, we offer voluntary Life options to keep you and your loved ones protected. • Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times. • Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals. • Support Your New Family: Guidehealth offers paid parental leave to give you the time you need. • Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.