[Hiring] Utilization Management Registered Nurse @Guidehealth

Role Description

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 YOU'LL 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 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

• 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.

Requirements

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

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: 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.