Utilization Management Registered Nurse
Source API remote eligibility restrictions: United StatesFull-TimeSenior
Salary72,000 - 75,000 USD per year
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Job Details
- Experience
- 5+ years
- Required Skills
- Microsoft ExcelPowerPoint
Requirements
- Active, unrestricted Registered Nurse (RN) license in Illinois.
- 5+ years of experience across varied healthcare settings.
- Knowledge of utilization review, managed care processes, and community health.
- Meets Illinois CE requirement of 20 hours per 2‑year RN license renewal cycle.
- Strong proficiency in Microsoft 365 (Word, Excel, PowerPoint, etc.).
- Excellent written, verbal, and organizational skills.
- Ability to prioritize effectively amid rapidly changing business needs.
- Demonstrates strong clinical judgment, compassion, and a positive attitude.
Responsibilities
- Complete timely review of healthcare services using appropriate medical criteria to support determinations.
- Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
- Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
- Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality‑of‑care review.
- Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives.
- Identify and refer eligible members to disease management programs to enhance care quality and continuity.
- Manage and document on‑call phone communications with members and providers on a rotational basis.
- Maintain confidentiality of all member information and case records.
- Participate in quality management initiatives and support related documentation, reporting, data collection, and committee activities.
- Maintain current knowledge of relevant regulations, multi‑jurisdictional requirements, medical group guidelines, and URAC standards.
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