Registered Nurse (RN) - Case Manager & Utilization Review Nurse

Registered Nurse (RN) – Case Manager & Utilization Review Nurse Wichita, United States | Posted on 05/25/2026 We are seeking an experienced and compassionate Registered Nurse to join our team in a dynamic dual-role position combining Case Management and Utilization Review responsibilities within a Third-Party Administrator (TPA) environment. This role is ideal for an RN who enjoys applying clinical expertise in a collaborative, non-bedside setting while supporting quality member outcomes, appropriate utilization of healthcare services, and effective care coordination. The nurse will work closely with providers, members, facilities, pharmacy benefit managers(PBMs), stop-loss carriers, insurance brokers, and health plan partners to ensure medically appropriate, cost-effective, and member-centered care. The ideal candidate is a collaborative and self-directed RN who thrives in a fast-paced managed care environment and enjoys integrating member advocacy with clinical review responsibilities. Successful candidates are adaptable, solutions-focused, data-driven, and committed to delivering high-quality, efficient care coordination and utilization management services while supporting positive member experiences and cost-effective healthcare outcomes. Job tasks are performed telephonically;however, this isnota remote position. Applicant must be ableto work on-site. Hours are Monday - Friday, 8:00 a.m. to 5 p.m. No on-call and no weekends Why Join Our Team Opportunity to utilize both clinical and analytical nursing skills in one integrated role Collaborative environment with providers, healthcare partners, PBMs, brokers, stop-loss carriers, and interdisciplinary teams Meaningful work focused on improving member outcomes, continuity of care, and healthcare affordability Professional growth opportunities in case management, utilization review, and managed care Predictable schedule and improved work-life balance compared to bedside nursing Supportive leadership and team-oriented culture Ability to impact member experience directly, care quality, and healthcare efficiency Case Management Responsibilities Coordinate and monitor member care plans across the continuum of care Communicate with providers, facilities, members, caregivers, brokers, and health plan partners to facilitate appropriate treatment and services Assist members in accessing in-network providers, facilities, and services to support cost-effective, coordinated care Collaborate with Pharmacy Benefit Managers (PBMs) and specialty pharmacies regarding members receiving specialty medications, including care coordination, adherence support, and medication access Follow up with members participating in wellness and care management programs to encourage engagement, monitor progress, and support health goals Identify barriers to care and assist in coordinating resources to support optimal member outcomes Facilitate transitions of care and discharge planning as appropriate Educate members regarding treatment plans, healthcare resources, preventive services, and care options Collaborate with stop-loss carriers regarding high-cost claims, large case management opportunities, and clinical updates as appropriate Communicate and coordinate with insurance brokers regarding member care initiatives, wellness engagement, and case management activities when applicable Maintain accurate and timely documentation in accordance with company policies and regulatory requirements Perform prospective, concurrent, and retrospective utilization reviews to assess medical necessity, appropriateness of care, and level of service Review clinical documentation and treatment requests using established evidence-based criteria and payer guidelines Apply utilization review criteria such as payer-specific standards Communicate with providers regarding authorization requirements, clinical information requests, and review determinations Ensure compliance with payer policies, accreditation standards, and regulatory requirements Assist in reducing unnecessary utilization and healthcare costs through proactive clinical review and care coordination Support denial prevention efforts through accurate documentation review and timely follow-up Participate in quality improvement initiatives and interdisciplinary case discussions Assist with identification and monitoring of high-cost claims and cases with potential stop-loss exposure Reporting & Performance Metrics Track, monitor, and report key performance indicators (KPIs) related to case management, utilization review, wellness engagement, turnaround times, member outcomes, and cost containment initiatives Maintain productivity and quality benchmarks established by the organization Assist leadership with identifying trends, opportunities for process improvement, and utilization patterns Prepare reports and clinical summaries for internal stakeholders, stop-loss carriers, and broker partners as needed Requirements Required Current, unrestricted Kansas or Multi-state Registered Nurse (RN) license Minimum of 4 years of clinical nursing experience Strong clinical assessment and critical thinking skills Excellent communication and interpersonal abilities Strong organizational skills and attention to detail Ability to manage multiple priorities in a fast-paced environment Proficiency with electronic medical records and clinical documentation systems Preferred Case Management Managed Care Health Plan or Insurance Setting Experience working with PBMs, specialty medications, wellness programs, or chronic disease management programs Experience collaborating with stop-loss carriers or insurance brokers preferred BSN preferred We offer a competitive compensation and benefits package including: Medical and dental insurance Paid time off Employee Assistance Program Flexible Spending Account Retirement plan options If you are passionate about member advocacy, critical thinking, care coordination, and working as part of an innovative healthcare team, we encourage you to apply today. #J-18808-Ljbffr