Utilization Management RN

WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, 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 has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.

Our Utilization Management RN (Registered Nurse) evaluates efficiency, appropriateness, and medical necessity for medical services, and procedures for our Health Plan. This role uses clinical knowledge to provide judgment to review medical services with evidence-based criteria, authorize requested services as appropriate. Our Utilization Management RN will be responsible for referring questionable cases to medical directors to prevent unnecessary procedures, treatments, or prolonged hospital stays. Work Location We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin

Enjoy working with healthcare professionals to facilitate appropriate and quality services in a cost-effective manner to positively impact medical loss ratio. Can work closely with Medical Directors to facilitate decision-making process for the Health Services department. Have experience reviewing medical and behavioral health prior authorization requests for medical necessity and appropriateness of requested treatment according to medical policies and evidence-based criteria. Have experience working closely with members of Health Services, and key contacts in Sales, Member Services, Claims, Provider Contracting, and Billing & Enrollment. Can document case summaries and refer cases to Medical Director that do not meet internal or external guidelines, policies, or medical criteria. Like to be accountable to monitor and maintain inventory in the Utilization Management queue to meet productivity standards. Enjoy evaluating, analyzing, and reporting trends in utilization changes in all healthcare delivery areas. Can make recommendations and implement changes consistent with Health Services objectives of quality care and reasonable cost. Would enjoy identifying opportunities and provide recommendations to improve department processes. Have Identified legal or liability issues and refer potential ethical or risk management issues to the appropriate department for resolution. Have participated in training new nursing staff on department workflows, policies, and procedures. Can work cross functionally to support other departmental efforts to ensure overall efficiency, quality, productivity, and compliance with all departmental, regulatory and URAC standards.