Utilization Management Registered Nurse (RN) - Remote

Utilization Management Registered Nurse (RN) - Remote

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.

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 timeframes.

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.

The salary range for this position is $70,000.00 to $75,000.00 per year based upon experience and qualifications.

At Guidehealth, our values come to life in everything we do.

• We are Driven by Accountability grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike.
• Always Growing, Always Learning staying curious and continuously improving inspires us to shape a better future for healthcare.
• With Collaborative Innovation, we solve problems creatively, making every experience better for our employees and the patients we serve.
• At Guidehealth, Every Voice Matters we believe our collective strength is rooted in the unique perspectives of each team member.
• And through Empathy in Action, we build stronger connections with those who count on us.
• This is what it means to be Alive with purpose. This is how we thrive together at Guidehealth.

While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:

• Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
• Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
• Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
• Have Peace of Mind: We provide Life and Disability insurance for those 'just in case' moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
• Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. Temporary employees and contractors are not eligible for benefits.

The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.

Diversity, inclusion, and belonging are at the core of Guidehealth's values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national origin, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other related medical conditions, or any other classification protected by federal, state, and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring, placement, promotion, transfer, demotion, layoff, termination, recruitment advertising, pay, and other forms of compensation, training, and general treatment during employment.

This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealth's custodianship as well as Guidehealth Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.

As a remote-first organization handling sensitive healthcare data, Guidehealth verifies candidate identity at multiple stages of the hiring and onboarding to safeguard patient privacy, data security, and compliance requirements.

Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection, capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 100 mbps download, 10 mbps upload. Please run a speed test here to confirm your internet connection meets these requirements.

At Guidehealth, we value transparency and collaboration as part of our commitment to excellence. As your primary employer, we kindly ask all team members to disclose any secondary employment, regardless of whether it may present a potential conflict of interest.

To ensure smooth teamwork and availability, employees must be accessible during our stated working hours. We foster connection and engagement by asking team members to join virtual meetings with their cameras on.