Utilization Management RN - Remote

at WPS Health Solutions in Marion, Illinois, United States

Job Description


Who We Are
WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready.

Culture Drives Our Success
WPS' Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive and empowering employee experience. We recognize the benefits of Diversity, Equity, and Inclusion as an investment in our workforce-both current and future-to effectively seek, leverage, and include diverse perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition

Role Snapshot
In this role you will become a thoughtful steward of our members healthcare benefits by evaluating the efficiency, appropriateness, and medical necessity of medical services, procedures, and facilities. This is done by reviewing evidence-based criteria and jurisdictional guidelines to make final determinations regarding medical necessity. You will be part of a growing team and will have the opportunity to evaluate medical care across the entire continuum of care.
How do I know this opportunity is right for me? If you:
Are familiar with MCG criteria and Utilization Management Platforms (e.g., Medecision-Aerial).
Have strong analytical, critical thinking and problem-solving skills.
Have strong communication skills and willingness to consult with our medical directors on difficult cases.
Have experience working within several electronic platforms (electronic medical record systems, utilization management systems, claims systems, etc.).
Keep current with medical knowledge and technical advances in the health care industry.
Excel at using independent judgement to educate customers or providers, and problem-solve unique customer issues for a variety of conditions and problems.
Possess strong change management skills which include accepting, supporting, and executing assignments in conditions of change which support department goals.
What will I gain from this role?
The opportunity to partner with WPS Medical Directors in decision making.
Exposure to a large variety of healthcare situations and medical conditions.
Experience working for a company that serves our nation's military, veterans, Guard and Reserves, and Medicare beneficiaries.
Working in a continuous performance feedback environment.
Minimum Qualifications
Bachelor of Science Degree in Nursing
1 or more years of related work experience
Active license as an RN in the State of Wisconsin or a valid multi-state compact license
Must maintain license after hired
Preferred Qualifications
5 or more years of experience as an RN in a varied clinical setting (hospital, clinic, home care, skilled nursing facility, etc.) with 2 or more years in some component of Managed Care (case management, disease management, prior authorization, utilization review, or quality assurance).
Working knowledge of knowledge of CPT/ICD 10/HCPCS codes.
Health insurance background in a Health Maintenance Organization (HMO), Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Advantage (MA) plans.

Remote Work Requirements
Wired (ethernet cable) internet connection from your router to your computer
High speed cable or fiber internet
Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at
Salary Range
$75,000 - $100,000
The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

Work Location
We are a remote-first organization and offer remote work in the following approved states:
Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, Wisconsin

Remote work option available
Performance bonus and/or merit increase opportunities
401(k) with... For full info follow application link.

Wisconsin Physicians Service Insurance Corporation is an Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities employer.

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Job Posting: 11923290

Posted On: May 23, 2024

Updated On: Jun 03, 2024

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