Utilization Management Registered Nurse, RN

Job not on LinkedIn

🕒 September 2

🧀 Wisconsin – Remote

🧀 Wisconsin – Remote

💵 $70k - $75k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 26%

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 • Apply approved medical necessity criteria to clinical information from medical records • Document clinical findings, criteria application, and determinations according to regulatory and accreditation standards • Communicate review determinations to providers, members, and other required parties within established timeframes • Collaborate with Medical Directors and Peer Reviewers on medical necessity, treatment plans, service intensity and duration, and quality-of-care concerns • Interface with ordering providers and provider organizations • Communicate with members or their representatives when appropriate • Integrate AI 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 with UM/PHM Committee materials and packets • Review cases affecting performance metrics and identify trends within assigned IPAs • Maintain confidentiality of member information and case documentation • Ensure compliance with federal and state regulations across multiple jurisdictions and medical groups • Apply medical group guidelines and URAC standards to review activities • Maintain professional growth and education consistent with nursing practice standards and the Illinois Nurse Practice Act

🎯 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 • Complete 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 based on rapidly changing business needs • Excellent clinical judgment, compassion, and a positive attitude • Interest in Informatics • Knowledge in Population Health and Disparities • Previous Health insurance experience • Internet connection with minimum 100 Mbps download and 10 Mbps upload • Ability to be accessible during stated working hours • Must follow security policies and procedures protecting PHI, PII, and Guidehealth intellectual property

🏖️ Benefits

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