Utilization Management Registered Nurse; RN; Remote

Utilization Management Registered Nurse (RN) - Remote

• Full-time

WHO IS GUIDEHEALTH?

Guidehealthis a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealthleverages remotely-embedded Health guides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealthempowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.

Join us as we put healthcare on a better path!!

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 time frames.

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 of 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.

WHAT YOU'LL NEED FOR SUCCESS

• 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.
• Strong organizational, writing, and speaking skills are necessary.
• Ability to prioritize and react based on rapidly changing business needs.
• Excellent…