Wisconsin Licensed Utilization Management RN

Job Summary

To support the Health Plan's efficiency and appropriateness of medical services, the full-time Wisconsin Licensed Utilization Management RN will evaluate medical necessity, authorize services, and collaborate with Medical Directors while working remotely from approved states.

Key responsibilities

• Evaluate the efficiency and appropriateness of medical services using evidence-based criteria
• Refer questionable cases to medical directors to prevent unnecessary procedures and prolonged hospital stays
• Document case summaries and monitor the Utilization Management queue to meet productivity standards

Required qualifications

• Current Registered Nurse (RN) licensure in Wisconsin
• 4+ years of experience as a Registered Nurse in varied clinical settings
• 2+ years of experience in Managed Care, specifically in Prior Authorization or Utilization Review
• Strong knowledge of current medical practices and coding
• Familiarity with health plan operations and payer/provider relationships