Utilization Management RN

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.

Start Date: 01/10/2027

Salary Range: $75,000 ~ $100,000

The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

Work Location

We are open to remote work in the following approved states:
Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin

How do I know this opportunity is right for me? If you:

• Enjoy working with healthcare professionals to facilitate appropriate and quality services in a cost-effective manner to positively impact medical loss ratio.
• Can work closely with Medical Directors to facilitate decision-making process for the Health Services department.
• Have experience reviewing medical and behavioral health prior authorization requests for medical necessity and appropriateness of requested treatment according to medical policies and evidence-based criteria.
• Have experience working closely with members of Health Services, and key contacts in Sales, Member Services, Claims, Provider Contracting, and Billing & Enrollment.
• Can document case summaries and refer cases to Medical Director that do not meet internal or external guidelines, policies, or medical criteria.
• Like to be accountable to monitor and maintain inventory in the Utilization Management queue to meet productivity standards.
• Enjoy evaluating, analyzing, and reporting trends in utilization changes in all healthcare delivery areas.
• Can make recommendations and implement changes consistent with Health Services objectives of quality care and reasonable cost.
• Would enjoy identifying opportunities and provide recommendations to improve department processes.
• Have Identified legal or liability issues and refer potential ethical or risk management issues to the appropriate department for resolution.
• Have participated in training new nursing staff on department workflows, policies, and procedures.
• Can work cross functionally to support other departmental efforts to ensure overall efficiency, quality productivity, and compliance with all departmental, regulatory and URAC standards.

• 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…