Utilization Management Registered Nurse (RN)
G
GuidehealthHealthcare
United StatesFull-TimeMiddle
Salary70,000 - 75,000 USD per year
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Job Details
- Experience
- Three years
Requirements
- Active and unrestricted Illinois State License as a Registered Nurse.
- Three years of experience in a variety of health care settings.
- Knowledge of utilization review, managed care, and community health.
- Strong organizational, writing, and speaking skills.
- Computer proficiency including Microsoft 365 (Word, Excel, PowerPoint).
- Ability to prioritize and adapt to changing business needs.
- Excellent clinical judgment and compassionate professional attitude.
- Interest in informatics and population health preferred.
- Previous health insurance experience preferred.
Responsibilities
- Perform timely reviews of healthcare services, including precertification and concurrent reviews.
- Apply medical necessity criteria and document clinical findings in accordance with regulatory standards.
- Collaborate with Medical Directors and Peer Reviewers on complex cases.
- Communicate review determinations to providers, members, and other parties.
- Integrate Artificial Intelligence (AI) into daily workflows and provide feedback for tool improvement.
- Coordinate care by referring patients to disease management or population health programs.
- Maintain strict confidentiality of member information and case documentation.
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