RN Care Management(Remote)

Utilization Management Registered Nurse (RN) - Remote

Full-time

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 Healthguides™ 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 Nurseis 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.

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.

Collaboratingwith the Medical Director and Peer Reviewer(s) on cases requiring further review of:

Medical necessity

Quality of care concerns

Integratingof Artificial Intelligence (AI) into daily workflow. Care Coordination & Quality Support

Initiatingreferrals of identified patients to disease management or population health programs to support continuity and quality of care.

Participatingin 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).

Ensure ongoing compliance with federal and state regulatory requirements across multiple jurisdictions and medical groups.

Integratingcurrent 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.

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.

Knowledge in Population Health and Disparities

Previous Health insurance experience

L earning — staying curious and continuously improving inspires us to shape a better future for healthcare.

I nnovation, we solve problems creatively, making every experience better for our employees and the patients we serve.

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. 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.

Have Peace of Mind: We provide Life and Disability insurance for those \"just in case\" moments. 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.

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.Diversity, inclusion, and belonging are at the core of Guidehealth’s values. 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.

OUR COMMITMENT TO PROTECTION OF PATIENT AND COMPANY DATA

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. 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.

REMOTE WORK TECHNICAL 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. We foster connection and engagement by asking team members to join virtual meetings with their cameras on.

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