Utilization Nurse

$75,000 - $75,000/Yr

Guidehealth - Waukegan, IL

Full-time - Mid Level

Remote - Waukegan, IL

About the position

The Utilization Nurse at Guidehealth is responsible for performing utilization review services in compliance with federal and state regulations, ensuring that healthcare treatment and services meet established standards. This role involves analyzing clinical documentation, communicating with medical professionals, and managing patient referrals to enhance care continuity. The position emphasizes operational excellence and aims to improve patient outcomes through effective utilization management.

Responsibilities

• Perform utilization review services in compliance with federal and state regulations and URAC standards.
• Obtain, analyze, and document all supporting clinical information within the documentation record.
• Complete timely reviews of healthcare services using appropriate medical criteria for clinical determinations.
• Communicate pre-certifications and concurrent review determinations for healthcare services to all required parties.
• Collaborate with the Medical Director and Peer Reviewers for cases requiring medical necessity reviews.
• Interface with ordering providers and provider organizations regularly.
• Initiate referrals for targeted patients into organized disease management programs.
• Manage and document after-hours phone calls from members and providers on a rotational basis.
• Maintain confidentiality of member information and case records.
• Participate in quality management activities and send client-specific benefit exhaustion letters upon request.
• Assist in the development of clinical and client-specific reports and materials for QM/UM Committee meetings.
• Maintain knowledge of regulatory requirements and medical group guidelines.
• Engage with the IT Department for technical support related to computer systems.

Requirements

• Registered Nurse with an active and unrestricted License in the state of Illinois.
• Five years of experience in various healthcare settings.
• Knowledge of utilization review, managed care, and community health.
• Proficient in computer skills including MS Word, Excel, and MS Access.
• Strong organizational, writing, and speaking skills.
• Ability to prioritize and react to rapidly changing business needs.
• Excellent clinical judgment, compassion, and a positive attitude.

Nice-to-haves

• An advanced degree or certification in Case Management, Utilization Review, and/or Quality.
• Interest in Informatics.
• Knowledge in Population Health and Disparities.

Benefits

• Work from Home: Fully remote position.
• Comprehensive Medical, Dental, and Vision plans.
• 401(k) plan with a 3% employer match on a 6% contribution.
• Life and Disability insurance, with voluntary Life options available.
• Employee Assistance Program (EAP) for support during tough times.
• Flexible Time Off to achieve work-life balance.
• Paid parental leave for new family members.
• Resources for professional growth and development.