Utilization Management Registered Nurse (RN) - Remote

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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. WHAT YOU'LL BE DOING 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. WHAT YOU'LL NEED FOR SUCCESS 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. WHAT WE'D LOVE FOR YOU TO HAVE Interest in Informatics Knowledge in Population Health and Disparities Previous Health insurance experience The salary range for this position is $70,000.00 to $75,000.00 per year based upon experience and qualifications. ALIVE with Purpose: How We Thrive at Guidehealth At Guidehealth , our values come to life in everything we do. We are Driven by A ccountability — grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike. Always Growing, Always L earning — staying curious and continuously improving inspires us to shape a better future for healthcare. With Collaborative I nnovation, we solve problems creatively, making every experience better for our employees and the patients we serve. At Guidehealth , Every V oice Matters — we believe our collective strength is rooted in the

Utilization Management Registered Nurse负责按照联邦和州法规、URAC标准以及Guidehealth政策执行利用审查活动。该角色应用既定的医疗必要性标准，从医疗记录中获取、分析并准确记录临床信息，以支持利用判定。UMRN与提供者、医疗主任和内部团队协作，确保审查流程及时、合规且高质量。您将要做的工作 利用审查临床判定 使用经批准的医疗必要性标准，对医疗服务进行及时审查，包括预认证和同步审查。按照监管和认证标准，准确记录临床发现、标准应用和判定。在规定时限内，向提供者、成员和其他 required parties 传达审查判定（书面和/或口头）。临床协作 与医疗主任和同行审查员就以下需要进一步审查的病例进行协作：医疗必要性 适当的治疗计划 住院或门诊服务的强度和持续时间 护理质量问题 定期与开具医嘱的提供者和提供者组织对接；在适当时与成员或其代表沟通。将人工智能（AI）整合到日常工作流程中。提供反馈并协助“教导”AI，使AI工具更可靠、更易使用。护理协调质量支持 将识别出的患者转介至疾病管理或人群健康项目，以支持护理的连续性和质量。参与质量管理活动和绩效改进计划。协助制定UM/PHM委员会材料和资料包，包括审查影响绩效指标的病例并识别指定IPA内的趋势。合规专业标准 对成员信息和病例文档严格保密。确保在多个司法管辖区和医疗集团中持续遵守联邦和州监管要求。将医疗集团指南和URAC标准的最新知识整合到日常审查活动中。按照当前护理实践标准和《伊利诺伊州护理实践法》，保持持续的专业成长和教育。您成功所需的条件 注册护士，持有有效且无限制的伊利诺伊州执照。三年在多种医疗环境中的工作经验。了解利用审查、管理式医疗和社区健康。伊利诺伊州要求护理专业人员在每2年执照续期周期内完成20小时继续教育。计算机技能，包括Microsoft 365（Word、Excel、PowerPoint等）。较强的组织、写作和表达能力是必要的。能够根据快速变化的业务需求进行优先排序和反应。出色的临床判断力、同理心和积极态度。我们希望您具备的条件 对信息学的兴趣 人群健康和差异方面的知识 既往健康保险经验 该职位的薪资范围为每年$70,000.00至$75,000.00，依据经验和资格而定。以目标而活：我们如何在Guidehealth蓬勃发展 在Guidehealth，我们的价值观体现在我们所做的一切中。我们以问责为驱动——以透明、可靠和诚信为基础，应对挑战和机遇。始终成长，始终学习——保持好奇并持续改进，激励我们塑造医疗保健更美好的未来。通过协作创新，我们创造性地解决问题，让每位员工和我们所服务的患者获得更好的体验。在Guidehealth，每一个声音都很重要——我们相信我们的集体力量植根于

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