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. Minimum 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.  Preferred Qualifications * Bachelor’s degree in nursing (BSN). * Certified Case Manager (CCM) and prior experience in Case Management (CM) within a health plan. * Background in commercial health insurance, including Point of Service (POS) or Preferred Provider Organization (PPO) plans. * Knowledge of Utilization Review Accreditation Commission (URAC). * Certified Managed Care Nurse (CMCN). * Technical experience with word processing, spreadsheets, and proficiency with electronic medical record (EMR) systems and/or other managed care software. Remote Work Requirements * High speed cable or fiber internet * Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net [https://speedtest.net]) * Please review Remote Worker FAQs [https://secure.wpsic.com/files/remote-work-faqs.pdf] for additional information 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/ [https://www.wpshealthsolutions.com/careers/]) Who We Are WPS, a health solutions company, [https://www.wpshealthsolutions.com/about/index.shtml] is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years [https://www.wpshealthsolutions.com/75/]. Proud to be military and veteran ready. Culture Drives Our Success WPS’ culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities. We are proud of the recognition we have received from local and national organization regarding our culture and workplace:  WPS Newsroom - Awards and Recognition. [https://www.wpshealthsolutions.com/news/?c=awards] Sign up for Job Alerts [http://recruiting2.ultipro.com/WIS1003/JobBoard/e6da0c90-f987-63dc-99a9-fb8c9014f57e/Account/Register?cancelUrl=https%3A%2F%2Frecruiting2.ultipro.com%2FWIS1003%2FJobBoard%2Fe6da0c90-f987-63dc-99a9-fb8c9014f57e%2F%3Fq%3DWPS%26o%3Drelevance&redirectUrl=%2FWIS1003%2FJobBoard%2Fe6da0c90-f987-63dc-99a9-fb8c9014f57e%2FJobSearchAgent] FOLLOW US! 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