Utilization Management Registered Nurse (RN) Remote

The Utilization Management Registered Nurse is responsible for performing utilization review activities in compliance with federal and state regulations URAC standards and Guidehealth policies. This role applies established medical necessity criteria to obtain analyze and accurately document clinical information from medical records in support of utilization determinations.

The UMRN works collaboratively with providers medical directors and internal teams to ensure timely compliant and high-quality review processes.

WHAT YOULL BE DOING

Utilization Review & Clinical Determinations

• 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.

Clinical Collaboration

• Collaborating with the Medical Director and Peer Reviewer(s) on cases requiring further review of:
  • Medical necessity
  • Appropriate treatment plans
  • Intensity and duration of inpatient or outpatient services
  • Quality of care concerns
• Interfacing routinely with ordering providers and provider organizations; communicate with members or their representatives when appropriate.
• Integrating of Artificial Intelligence (AI) into daily workflow. Offer feedback and assist in teaching AI to make AI tools more reliable and user-friendly.

Care Coordination & Quality Support

• Initiating referrals of identified patients to disease management or population health programs to support continuity and quality of care.
• Participating in quality management activities and performance improvement initiatives.
• Assisting in the development of UM/PHM Committee materials and packets including review of cases impacting performance metrics and identification of trends within assigned IPA(s).

Compliance & Professional Standards

• Maintaining strict confidentiality of member information and case documentation.
• Ensure ongoing compliance with federal and state regulatory requirements across multiple jurisdictions and medical groups.
• Integrating current knowledge of medical group guidelines and URAC standards into daily review activities.
• Maintaining continued professional growth and education consistent with current nursing practice standards and the Illinois Nurse Practice Act.

Qualifications :

WHAT YOULL NEED FOR SUCCESS

• 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.

WHAT WED LOVE FOR YOU TO HAVE

• Interest in Informatics
• Knowledge in Population Health and Disparities
• Previous Health insurance experience

Additional Information :

The salary range for this position is $70000.00 to $75000.00 per year based upon experience and qualifications.

ALIVE with Purpose: How We Thrive at Guidehealth 

At Guidehealth our values come to life in everything we do. 

• We are Driven by Accountability grounded in transparency reliability and integrity as we navigate challenges and opportunities alike. 
• Always Growing Always Learning staying curious and continuously improving inspires us to shape a better future for healthcare. 
• With Collaborative Innovation we solve problems creatively making every experience better for our employees and the patients we serve. 
• At Guidehealth Every Voice Matters we believe our collective strength is rooted in the unique perspectives of each team member. 
• And through Empathy in Action we build stronger connections with those who count on us. 
• This is what it means to be ALIVE with purpose. This is how we thrive together at Guidehealth. 

BENEFITS:

While you are hard at work advancing value-based healthcare we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:

• 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: Welcoming a new family member takes time and commitment. 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.

All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. Temporary employees and contractors are not eligible for benefits.

COMPENSATION:

The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include but are not limited to: skill set years of relevant experience education location and licensure/certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT 

Diversity inclusion and belonging are at the core of Guidehealths values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race religious creed color age sex sexual orientation and identity national origin citizenship religion marital status familial status physical sensory or medical disability Family and Medical Leave military or veteran status pregnancy childbirth or other related medical conditions or any other classification protected by federal state and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring placement promotion transfer demotion layoff termination recruitment advertising pay and other forms of compensation training and general treatment during employment. 

OUR COMITTMENT TO PROTECTION OF PATIENT AND COMPANY DATA

This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealths custodianship as well as Guidehealth Intellectual Properties.  For any security-specific roles the responsibilities would be further defined by the hiring manager. 

As a remote-first organization handling sensitive healthcare data Guidehealth verifies candidate identity at multiple stages of the hiring and onboarding to safeguard patient privacy data security and compliance requirements.

REMOTE WORK TECHNICAL REQUIREMENTS

Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 100 mbps download 10 mbps upload. Please run a speed test here to confirm your internet connection meets these requirements. 

SECONDARY EMPLOYMENT

At Guidehealth we value transparency and collaboration as part of our commitment to excellence. As your primary employer we kindly ask all team members to disclose any secondary employment regardless of whether it may present a potential conflict of interest. 

To ensure smooth teamwork and availability employees must be accessible during our stated working hours. We foster connection and engagement by asking team members to join virtual meetings with their cameras on.

Remote Work :

Yes

Employment Type :

Full-time