Utilization Management Registered Nurse (RN) - Remote

About the role

Guidehealth is 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, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.

Responsibilities

• Utilization Review & Clinical Determinations
  • Perform timely reviews of healthcare services, including precertification and concurrent reviews, using approved medical necessity criteria.
  • Accurately document clinical findings, criteria application, and determinations in accordance with regulatory and accreditation standards.
  • Communicate review determinations (written and/or verbal) to providers, members, and other required parties within established timeframes.
• Clinical Collaboration
  • Collaborate 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, and quality of care concerns.
  • Interface routinely with ordering providers and provider organizations; communicate with members or their representatives when appropriate.
  • Integrate 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
  • Initiate referrals of identified patients to disease management or population health programs to support continuity and quality of care.
  • Participate in quality management activities and performance improvement initiatives.
  • Assist 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
  • Maintain strict confidentiality of member information and case documentation.
  • Ensure ongoing compliance with federal and state regulatory requirements across multiple jurisdictions and medical groups.
  • Integrate current knowledge of medical group guidelines and URAC standards into daily review activities.
  • Maintain continued professional growth and education consistent with current nursing practice standards and the Illinois Nurse Practice Act.

Qualifications

• 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.
• Computer skills including Microsoft 365 (Word, Excel, PowerPoint, etc).
• Strong organizational, writing, and speaking skills are necessary.
• Ability to prioritize and react based on rapidly changing business needs.
• Excellent clinical judgment, compassion, and a positive attitude.
• Interest in Informatics.
• Knowledge in Population Health and Disparities.
• Previous Health insurance experience.

Pay

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

Benefits

• Work from Home: Guidehealth is a fully remote company, providing flexibility to spend less time commuting and more time focusing on professional goals and personal needs.
• Health Coverage: Comprehensive Medical, Dental, and Vision plans.
• Retirement Planning: 401(k) plan with a 3% employer match to your 6% contribution.
• Insurance Protection: Life and Disability insurance; voluntary Life options.
• Employee Assistance: Access to an Employee Assistance Program (EAP) for support during tough times.
• Paid Time Off: Paid time off plans to help achieve work-life balance and meet personal goals.
• Parental Leave: Paid parental leave to support welcoming a new family member.
• Learning & Development: Resources dedicated to professional growth and career advancement.
• Eligibility: All full-time employees working 30 hours per week or more are eligible for the comprehensive benefits package.