[Hiring] Utilization Management RN @WPS—A health solutions company

Role Description

Our Utilization Management RN (Registered Nurse) evaluates efficiency, appropriateness, and medical necessity for medical services, and procedures for our Health Plan. This role uses clinical knowledge to provide judgment to review medical services with evidence-based criteria, authorize requested services as appropriate. Our Utilization Management RN will be responsible for referring questionable cases to medical directors to prevent unnecessary procedures, treatments, or prolonged hospital stays.

We’re looking for someone who’s open to cross-training in Case Management (CM), with the potential for the role to grow into a combined UM/CM position or transition into CM in the future.

Qualifications

• Registered Nurse (RN) with current licensure in the state of Wisconsin.
• 4 or more years of experience as a Registered Nurse in varied clinical settings (i.e., hospital, clinic, home care, skilled nursing facility, etc.).
• 2 or more years of experience in Managed Care (i.e., prior authorization, utilization review), preferably within a commercial health plan.
• Demonstrated experience managing and coordinating care effectively for case managed members.
• Strong knowledge of current medical practices, medical coding, trends and patterns of care.
• Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
• Strong diverse experience and expertise that includes:
• The ability to work independently, manage a case load, and prioritization.
• Excellent analytical, critical thinking, problem-solving skills and decision-making skills.
• Excellent communication and interpersonal skills to work with members, providers, and teams.
• Proficiency in Microsoft Office and healthcare software and systems.

Requirements

• Bachelor’s degree in nursing (BSN) - Preferred.
• Certified Case Manager (CCM) and prior experience in Case Management (CM) within a health plan - Preferred.
• Background in commercial health insurance, including Point of Service (POS) or Preferred Provider Organization (PPO) plans - Preferred.
• Knowledge of Utilization Review Accreditation Commission (URAC) - Preferred.
• Certified Managed Care Nurse (CMCN) - Preferred.
• Technical experience with word processing, spreadsheets, and proficiency with electronic medical record (EMR) systems and/or other managed care software - Preferred.

Benefits

• Remote and hybrid work options available.
• Performance bonus and/or merit increase opportunities.
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately).
• Competitive paid time off.
• Health insurance, dental insurance, and telehealth services start DAY 1.
• Professional and Leadership Development Programs.
• Review additional benefits: ( https://www.wpshealthsolutions.com/careers/ ).