Guidehealth is hiring an Utilization Management Registered Nurse

Guidehealth is looking for a Utilization Management Registered Nurse to serve as a Clinical Care Manager. In this detailed and collaborative role, you will advance high-quality, compliant, and patient-centered care through precise utilization review, directly contributing to the integrity of care management and the member experience.

What You'll Do

• Complete timely review of healthcare services using appropriate medical criteria to support determinations.
• Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
• Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
• Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality-of-care review.
• Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives.
• Identify and refer eligible members to disease management programs to enhance care quality and continuity.
• Manage and document on-call phone communications with members and providers on a rotational basis.
• Maintain confidentiality of all member information and case records.
• Participate in quality management initiatives and support related documentation, reporting, data collection, and committee activities.
• Prepare benefit exhaustion letters upon request.
• Assist with the design and maintenance of clinical and/or client-specific reports, spreadsheets, and analyses.
• Maintain current knowledge of relevant regulations, multi-jurisdictional requirements, medical group guidelines, and URAC standards.
• Maintain ongoing professional education and growth aligned with Illinois nursing regulations and contemporary clinical practice.

What We're Looking For

• Active, unrestricted Registered Nurse (RN) license in Illinois.
• 5+ years of experience across varied healthcare settings.
• Knowledge of utilization review, managed care processes, and community health.
• Meets Illinois CE requirement of 20 hours per 2-year RN license renewal cycle.
• Strong proficiency in Microsoft 365 (Word, Excel, PowerPoint, etc.).
• Excellent written, verbal, and organizational skills.
• Ability to prioritize effectively amid rapidly changing business needs.
• Demonstrates strong clinical judgment, compassion, and a positive attitude.

Nice to Have

• Advanced degree or certification in Case Management, Utilization Review, and/or Quality.
• Interest in Clinical Informatics.
• Knowledge of Population Health and Health Disparities.
• Previous experience in health insurance or managed care settings.

Technical Stack

• Microsoft 365

Benefits & Compensation

• Comprehensive Medical, Dental, and Vision plans.
• 401(k) plan includes a 3% employer match to your 6% contribution.
• Life and Disability insurance.
• Voluntary Life options.
• Employee Assistance Program (EAP).
• Paid time off plans.
• Paid parental leave.
• Various resources dedicated to learning and development.

Work Mode

Guidehealth is a fully remote company, and this role will be performed from home.

We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national origin, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other related medical conditions, or any other classification protected by federal, state, and local laws and ordinances.