Utilization Management Registered Nurse (RN) - Remote

The Utilization Management Registered Nurse (RN) 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.

Responsibilities

Utilization Review & Clinical Determinations

• Perform timely reviews of healthcare services, including precertification and concurrent reviews, using approved medical necessity criteria.
• Accurately document clinical findings, criteria application, and determinations in accordance with regulatory and accreditation standards.
• Communicate review determinations to providers, members, and other required parties within established timeframes.

Clinical Collaboration

• Collaborate with the Medical Director and Peer Reviewer(s) on cases requiring further review of medical necessity, treatment plans, and quality of care.
• Interface routinely with ordering providers, provider organizations, and members.
• Integrate Artificial Intelligence (AI) into daily workflow and provide feedback to improve AI tools.

Care Coordination & Quality Support

• Initiate referrals of identified patients to disease management or population health programs.
• Participate in quality management activities and performance improvement initiatives.

Compliance & Professional Standards

• Maintain strict confidentiality of member information and case documentation.
• Ensure ongoing compliance with federal and state regulatory requirements and URAC standards.

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.
• Computer skills including Microsoft 365.
• Strong organizational, writing, and speaking skills.