Utilization Management Registered Nurse (RN) - Remote

About the position 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. Responsibilities • 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. • 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, and 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. • 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). • 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. Requirements • 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. Nice-to-haves • Interest in Informatics • Knowledge in Population Health and Disparities • Previous Health insurance experience Benefits • Work from Home • Comprehensive Medical, Dental, and Vision plans • 401(k) plan with a 3% employer match to your 6% contribution • Life and Disability insurance • Voluntary Life options • Employee Assistance Program (EAP) • Paid time off plans • Paid parental leave • Resources dedicated to learning and development