Job Description

Job Description

Job Description

This is a full-time remote work from home position.

The utilization management review nurse will conduct reviews for hospitalizations, post-acute admissions, prior authorizations, and appeals. They will condense the information that is provided and use national standard guidelines to determine if the clinical information received meets criteria. They will work collaboratively with both medical directors and case managers.

• Use clinical experience to assess, plan, implement, coordinate, monitor, and evaluate options to ensure appropriate healthcare services/benefits for members.
• Collect clinical information and applies the appropriate clinical criteria/guideline, policy, and clinical judgment to provide coverage determination.
• Communicates with providers and other parties to facilitate care.
• Identifies members for referral opportunities.
• Ability to work autonomously 
• Ability to multi-task, prioritize and effectively adapt to a fast-paced changing environment.
• Strong written and verbal communication skills.
• Intermediate typing skills.
• Demonstrated organizational skills and communication skills required.
• Ability to learn and retain in a complex environment.
• Ability to seamlessly, multi-task while using multiple system for a review.
• This position may require working weekends and/or holidays.
• This role involves sitting for extended periods and using a computer extensively.
• Must have high speed internet access – preferably ethernet connection.

Qualifications:

• 3+ years of experience as a registered nurse or licensed practical nurse
• Must have an active and unrestricted nursing license in (state – this will be dependent on the state and if they are compact or if they are single state licenses. This section will change pending the state)
• 1+ years of med/surg experience - preferred
• Experience with Microsoft Office Applications (Outlook, Teams, Excel, Word)

Company Description

WellGuide Health redefines care and case management by taking a proactive and personalized approach to member engagement. Unlike traditional care management companies that rely on basic outreach methods like phone calls, emails, and letters, WellGuide Health goes further by involving employers in the process to help connect with members who are difficult to reach. Our strategy focuses on personalized care coordination, tailored interventions, and continuous engagement through multiple touchpoints. We work closely with employers to provide non-PHI-specific support, leveraging additional points of contact to encourage member participation. This unique approach improves health outcomes, reduces healthcare costs, and enhances productivity by ensuring members receive timely, coordinated care.

By actively engaging members, collaborating with healthcare providers, and integrating employer involvement, WellGuide Health delivers a seamless and effective care experience that results in better outcomes and significant cost savings. Our data-driven strategies and continuous monitoring ensure that care plans are always relevant, responsive, and aligned with each member's unique needs, making WellGuide Health the leading choice for comprehensive care management that goes above and beyond standard industry practices.

Company Description

WellGuide Health redefines care and case management by taking a proactive and personalized approach to member engagement. Unlike traditional care management companies that rely on basic outreach methods like phone calls, emails, and letters, WellGuide Health goes further by involving employers in the process to help connect with members who are difficult to reach. Our strategy focuses on personalized care coordination, tailored interventions, and continuous engagement through multiple touchpoints. We work closely with employers to provide non-PHI-specific support, leveraging additional points of contact to encourage member participation. This unique approach improves health outcomes, reduces healthcare costs, and enhances productivity by ensuring members receive timely, coordinated care.\r\n \r\nBy actively engaging members, collaborating with healthcare providers, and integrating employer involvement, WellGuide Health delivers a seamless and effective care experience that results in better outcomes and significant cost savings. Our data-driven strategies and continuous monitoring ensure that care plans are always relevant, responsive, and aligned with each member's unique needs, making WellGuide Health the leading choice for comprehensive care management that goes above and beyond standard industry practices.

Job Tags

Holiday work, Full time, Remote job, Weekend work,

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