utilization management um nurse

Brighton Health Plan Solutions

<div>
 
 About The Role
 
 
 
 BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member&rsquo;s benefit coverage while working remotely.
 
 
 
 Primary Responsibilities
 
 
 
 <ul>
 <li>
 Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures
 </li>
 <li>
 Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments
 </li>
 <li>
 Collaborates with healthcare partners to ensure timely review of services and care
 </li>
 <li>
 Provides referrals to Case management, Disease Management, Appeals &amp; Grievances, and Quality Departments as needed
 </li>
 <li>
 Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
 </li>
 <li>
 Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate
 </li>
 <li>
 Triages and prioritizes cases and other assigned duties to meet required turnaround times
 </li>
 <li>
 Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations
 </li>
 <li>
 Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements
 </li>
 <li>
 Duties as assigned
 
 
 </li>
 </ul>
 
 Essential Qualifications
 
 
 
 <ul>
 <li>
 Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment
 </li>
 <li>
 Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
 </li>
 <li>
 Must be able to work independently
 </li>
 <li>
 Must be detail oriented and have strong organizational and time management skills
 </li>
 <li>
 Adaptive to a high pace and changing environment- flexibility in assignment
 </li>
 <li>
 Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review
 </li>
 <li>
 Proficient in MCG and CMS criteria sets
 </li>
 <li>
 Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred
 </li>
 <li>
 Working knowledge of URAC and NCQA
 </li>
 <li>
 2+ years&rsquo; experience in a UM team within managed care setting
 </li>
 <li>
 3+ years&rsquo; experience in clinical nurse setting preferred
 </li>
 <li>
 TPA Experience preferred
 
 
 </li>
 </ul>
 
 About
 
 
 
 At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you&rsquo;ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you&rsquo;ll be encouraged to bring your authentic self to work with all of your unique abilities.
 
 
 Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today&rsquo;s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today&rsquo;s challenges into tomorrow&rsquo;s solutions.
 
 
 Come be a part of the Brightest Ideas in Healthcare&trade;.
 
 
 
 Company Mission
 
 
 
 Transform the health plan experience &ndash; how health care is accessed and delivered &ndash; by bringing outstanding products and services to our partners.
 
 
 
 Company Vision
 
 
 
 Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.
 
 
 Powered by JazzHR
 
 
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</div>

Utilization Management Nurse

Humana

<div><h1 class="jobSectionHeader">Become a part of our caring community and help us put health first 
</h1>
Why Humana? 
At Humana, caring is everything. You look after our members and patients. We look after you. If caring means something to you too, we've got a spot for you. We design competitive and flexible benefits packages to provide our employees a sense of financial security now and in the future. 
Fostering a culture of inclusion is part of the fabric of who we are. We must have a workplace that reflects the people we serve and thrives in part because every person can bring their whole self to work to make an impact. Our vibrant, diverse culture and environment of inclusion is one of our greatest strengths. 
About Humana Healthy Horizons 
Humana Healthy Horizons is more than a health plan. We're human care. Humana Healthy Horizons focuses on helping people achieve their best health. Our dedicated strategies across various markets and states are enabled by partnerships with state and local governments, community-based organizations, and national partners committed to removing barriers to helping people achieve their best health. 
The Utilization Management (UM) Nurse 2 uses clinical nursing skills to support the coordination, documentation, and communication of medical services and benefit administration determinations. The Utilization Management Nurse 2's work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Position Responsibilities:<ul><li>
Uses clinical knowledge toward interpreting criteria and procedures to provide the best and most appropriate treatment, care, or services for Enrollees</li><li>
Coordinates and communicates with Providers, Enrollees or other parties to facilitate optimal care and treatment</li><li>
Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas</li><li>
Uses judgement regarding own work methods, occasionally in ambiguous situation, and receiving guidance where needed</li><li>
Follows established guidelines and procedures</li><li>
Periodic travel to Humana Oklahoma City office for meetings and training</li></ul><h1 class="jobSectionHeader"> 

Use your skills to make an impact 

</h1>Required Qualifications:<ul><li>
Must Reside in Oklahoma</li><li>
An active Licensed Registered Nurse (RN), unrestricted</li><li>
3+ years of prior clinical experience, preferably in an acute care, skilled or rehabilitation clinical setting</li><li>
Comprehensive knowledge of Microsoft Excel and Outlook</li><li>
Ability to work a weekend rotation</li></ul>
Preferred Qualifications:<ul><li>
Previous experience in Utilization Management</li><li>
Prior experience with EPIC Programs</li><li>
Previous remote work experience</li></ul>
WAH Internet Statement
To ensure Home or Hybrid Home/Office employees&rsquo; ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:<ul><li>
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.</li><li>
Satellite, cellular and microwave connection can be used only if approved by leadership.</li><li>
Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.</li><li>
Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.</li><li>
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.</li></ul>
HireVue
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
SSN Alert
Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana&rsquo;s secure website.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. 

$71,100 - $97,800 per year 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.<h1 class="jobSectionHeader"> 
About us 
</h1>
Humana Inc. (NYSE: HUM) is committed to putting health first &ndash; for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. 
 
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.</div>

Utilization Management RN - Physical Health

Matrix Providers

Matrix Providers is hiring a Registered Nurse - Utilization Management to join our team of talented professionals who provide health care services to our Military Service Members and their families in at Buckley AFB, Aurora, CO. Employment Status: Full Time Compensation: $36.57 - $51.96 per hour Benefits: Competitive financial package with a comprehensive insurance package including health, dental, vision, and life coverage. Accrued Paid Time Off (PTO) Paid Holidays (Outlined in Handbook) 401(k) Plan Minimum Requirements Registered Nurse (RN) Utilization Management: Degree/Education: Bachelor&rsquo;s degree in nursing. Certifications: Basic Life Support Certified/certification eligible in relevant specialty such as: Certified Managed Care Nurse through the American Board of Managed Care Nurses; Certification in Health Care Quality and Management (HCQM) through American Board of Quality Assurance and Utilization Review Physicians (ABQARP) Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center Utilization Management Accreditation through National Committee for Quality Assurance (NCQA) are desired. Experience: A minimum of 36 months total nursing experience in a direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 12 recent consecutive months within the last 12 months. Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse. Overview: Serve as a key member of the Utilization Management team, providing comprehensive support to TRICARE beneficiaries. Function independently to ensure appropriate, cost-effective healthcare delivery within TRICARE and Military Health System (MHS) guidelines. Key Responsibilities: Manage a robust Utilization Management program, conducting reviews (prospective, concurrent, retrospective) to ensure proper use of patient care services. Analyze trends, identify inefficiencies, and recommend process improvements to optimize patient care at appropriate levels. Coordinate with military and civilian providers to ensure services meet medical necessity, cost-effectiveness, and TRICARE standards. Serve as a resource for primary care managers, interpreting guidelines, monitoring referrals, and optimizing MTF and civilian healthcare services. Identify and address access/utilization challenges, including enrollment, procedures, inpatient admissions, claims, and grievances. Conduct systematic monitoring and evaluation of utilization metrics, identifying areas for improvement and reporting findings. Provide training to healthcare providers on referral practices for quality and cost-effective care. Qualifications: Advanced knowledge of TRICARE, MHS policies, and referral management systems. Strong analytical skills with the ability to interpret data and recommend solutions. Experience with Electronic Health Records (MHS Genesis preferred). Interpersonal skills to collaborate effectively with diverse teams and stakeholders. Desired Skills: Familiarity with government regulations, healthcare financing, and quality/risk management. Proficiency in office automation software and DHA-approved documentation systems. This role supports healthcare excellence by optimizing resources, improving care quality, and ensuring compliance with TRICARE and DHA standards. We support our employees with an accessible dedicated representative to assist you throughout the duration of your contract. We firmly believe that a healthy work/life balance enables you to perform at your best. Our mission is to serve America&rsquo;s military family by aligning exceptional healthcare workers like you with rewarding career opportunities. Come home to Matrix. #INDKK

Registered Nurse - Utilization Management

CVS Health

<div>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.
Position Summary
Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours.<ul><li>
Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.</li><li>
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care</li><li>
Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs</li><li>
Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization</li><li>
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.</li><li>
Typical office working environment with productivity and quality expectations.</li><li>
Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.</li><li>
Sedentary work involving periods of sitting, talking, listening.</li><li>
Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.</li><li>
Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.</li><li>
Effective communication skills, both verbal and written</li></ul><div>
Required Qualifications 
<ul><li>2+ years of experience as a Registered Nurse in adult acute care/critical care setting
</li></ul></div><ul><li>Must have active current and unrestricted RN licensure in state of residence</li><li>Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours</li></ul><div> 
Preferred Qualifications 
<ul><li>2+ years of clinical experience required in med surg or specialty area</li><li>Managed Care experience preferred, especially Utilization Management</li></ul></div><ul><li>Preference for those residing in ET zones</li></ul>
Education
Associates Degree required
BSN preferred
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$29.10 - $62.32
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in our comprehensive and competitive mix of pay and benefits &ndash; investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:<ul><li>
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.</li><li>
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.</li><li>
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.</li></ul>
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 03/31/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</div>

Utilization Management Nurse Consultant

Guidehealth

<div>
 
 Company Description
 
 
 
 
 WHO IS GUIDEHEALTH?
 
 
 
 Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides&trade; and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients.
 
 
 
 Job Description
 
 
 
 
 Job Description
 
 
 
 We are seeking a
 
 Clinical Care Manager
 
 who is passionate about advancing high‑quality, compliant, patient‑centered care through precise and timely Utilization Review. In this role, you will apply clinical expertise and regulatory knowledge to evaluate healthcare services, ensure medically necessary care, support provider decision-making, and promote effective care coordination.
 
 
 This is a detailed, analytical, and highly collaborative role that directly contributes to the integrity of care management operations and the member experience.
 
 
 
 What You&rsquo;ll Be Doing
 
 
 
 
 Utilization Review &amp; Clinical Determinations
 
 
 
 <ul>
 <li>
 Complete timely review of healthcare services using appropriate medical criteria to support determinations.
 </li>
 <li>
 Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
 </li>
 <li>
 Communicate precertification and concurrent review decisions&mdash;verbally and in writing&mdash;to required parties within defined timeframes.
 
 
 </li>
 </ul>
 
 Clinical Consultation &amp; Collaboration
 
 
 
 <ul>
 <li>
 Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality‑of‑care review.
 </li>
 <li>
 Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives.
 
 
 </li>
 </ul>
 
 Care Coordination &amp; Member Support
 
 
 
 <ul>
 <li>
 Identify and refer eligible members to disease management programs to enhance care quality and continuity.
 </li>
 <li>
 Manage and document on‑call phone communications with members and providers on a rotational basis.
 
 
 </li>
 </ul>
 
 Compliance, Quality &amp; Documentation
 
 
 
 <ul>
 <li>
 Maintain confidentiality of all member information and case records.
 </li>
 <li>
 Participate in quality management initiatives and support related documentation, reporting, data collection, and committee activities.
 </li>
 <li>
 Prepare benefit exhaustion letters upon request.
 </li>
 <li>
 Assist with the design and maintenance of clinical and/or client-specific reports, spreadsheets, and analyses.
 </li>
 <li>
 Maintain current knowledge of relevant regulations, multi‑jurisdictional requirements, medical group guidelines, and URAC standards.
 
 
 </li>
 </ul>
 
 Professional Development
 
 
 
 <ul>
 <li>
 Maintain ongoing professional education and growth aligned with Illinois nursing regulations and contemporary clinical practice.
 
 
 </li>
 </ul>
 Qualifications
 
 
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Active, unrestricted Registered Nurse (RN) license in Illinois.
 </li>
 <li>
 5+ years of experience across varied healthcare settings.
 </li>
 <li>
 Knowledge of utilization review, managed care processes, and community health.
 </li>
 <li>
 Meets Illinois CE requirement of 20 hours per 2‑year RN license renewal cycle.
 </li>
 <li>
 Strong proficiency in Microsoft 365 (Word, Excel, PowerPoint, etc.).
 </li>
 <li>
 Excellent written, verbal, and organizational skills.
 </li>
 <li>
 Ability to prioritize effectively amid rapidly changing business needs.
 </li>
 <li>
 Demonstrates strong clinical judgment, compassion, and a positive attitude.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Advanced degree or certification in Case Management, Utilization Review, and/or Quality.
 </li>
 <li>
 Interest in Clinical Informatics.
 </li>
 <li>
 Knowledge of Population Health and Health Disparities.
 </li>
 <li>
 Previous experience in health insurance or managed care settings.
 
 
 </li>
 </ul>
 Additional Information
 
 
 All your information will be kept confidential according to EEO guidelines.
 
 
 
 ALIVE with Purpose: How We Thrive at Guidehealth
 
 
 
 At Guidehealth, our values come to life in everything we do.
 
 
 <ul>
 <li>
 We are Driven by Accountability &mdash; grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike.
 </li>
 <li>
 Always Growing, Always Learning &mdash; staying curious and continuously improving inspires us to shape a better future for healthcare.
 </li>
 <li>
 With Collaborative Innovation, we solve problems creatively, making every experience better for our employees and the patients we serve.
 </li>
 <li>
 At Guidehealth, Every Voice Matters &mdash; we believe our collective strength is rooted in the unique perspectives of each team member.
 </li>
 <li>
 And through Empathy in Action, we build stronger connections with those who count on us.
 </li>
 <li>
 This is what it means to be ALIVE with purpose. This is how we thrive &mdash; together &mdash; at Guidehealth.
 
 
 </li>
 </ul>
 
 BENEFITS:
 
 
 
 While you are hard at work advancing value-based healthcare, we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:
 
 
 <ul>
 <li>
 Work from Home: Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
 </li>
 <li>
 Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
 </li>
 <li>
 Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
 </li>
 <li>
 Have Peace of Mind: We provide Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to keep you and your loved ones protected.
 </li>
 <li>
 Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
 </li>
 <li>
 Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
 </li>
 <li>
 Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
 </li>
 <li>
 Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.
 
 
 </li>
 </ul>
 All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. Temporary employees and contractors are not eligible for benefits.
 
 
 
 COMPENSATION:
 
 
 
 The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.
 
 
 
 OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT
 
 
 
 Diversity, inclusion, and belonging are at the core of Guidehealth&rsquo;s values. 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. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring, placement, promotion, transfer, demotion, layoff, termination, recruitment advertising, pay, and other forms of compensation, training, and general treatment during employment.
 
 
 
 Our Comittment To Protection Of Patient And Company Data
 
 
 
 This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealth&rsquo;s custodianship as well as Guidehealth Intellectual Properties. For any security-specific roles, the responsibilities would be further defined by the hiring manager.
 
 
 As a remote-first organization handling sensitive healthcare data, Guidehealth verifies candidate identity at multiple stages of the hiring and onboarding to safeguard patient privacy, data security, and compliance requirements.
 
 
 
 Remote Work Technical Requirements
 
 
 
 Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection, capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 100 mbps download, 10 mbps upload. Please run a speed test here to confirm your internet connection meets these requirements.
</div>

Utilization Management Registered Nurse

Toney HealthCare Consulting, LLC

The Supervisor, Utilization Management &amp; Appeals is responsible for overseeing daily Utilization Management (UM) and Appeals operations while also providing hands-on overnight, weekend and holiday coverage. This role combines clinical leadership with operational execution to ensure timely, accurate, and compliant utilization and appeal workflows. The Supervisor provides guidance and oversight to UM nurses, supports complex case preparation, ensures regulatory compliance, and maintains operational continuity.This position plays a critical role in ensuring high-quality clinical documentation, effective workload management, and coordination with medical directors, providers, and internal stakeholders.Essential Functions / Key ResponsibilitiesLeadership &amp; Operations<ul><li>Supervise daily activities of UM and Appeals staff, including nurses.</li><li>Monitor workloads, productivity, and performance metrics to maintain service-level and regulatory compliance.</li><li>Provide clinical oversight and coaching on complex UM and Appeals cases; escalate to medical directors as appropriate.</li><li>Train, mentor, and evaluate team members; participate in hiring, corrective action, and performance management processes.</li><li>Develop, implement, and maintain standard operating procedures (SOPs) across UM and Appeals workflows.</li><li>Participate in audits, reporting, and continuous performance improvement initiatives.</li><li>Collaborate cross-functionally with medical directors, case management, providers, and client stakeholders to ensure appropriate care and avoid unnecessary utilization.</li></ul>Clinical &amp; Overnight Coverage<ul><li>Provide overnight, weekend, and holiday operational coverage to maintain continuous UM and Appeals workflows.</li><li>Manage and process work queues, including screening requests, creating authorizations, routing cases, and generating member and provider notifications.</li><li>Prepare accurate and thorough clinical summaries and documentation for physician review (non-decisional).</li><li>Review case data for completeness, accuracy, and regulatory alignment prior to submission.</li><li>Support Appeals intake, screening, and case preparation in accordance with appeal protocols.</li><li>Work independently during overnight and weekend hours with minimal supervision, maintaining productivity during low call-volume periods through assigned tasks.</li></ul>Compliance &amp; Knowledge Management<ul><li>Ensure adherence to federal and state regulations, NCQA/URAC standards, and payer-specific UM and Appeals requirements.</li><li>Maintain strong working knowledge of InterQual and/or MCG criteria.</li><li>Stay current on healthcare regulations, utilization trends, and evidence-based clinical guidelines.</li><li>Ensure consistent application of UM and Appeals policies across all shifts.</li></ul>Core Competencies<ul><li>Leads by example; fosters accountability, trust, and team engagement.</li><li>Thrives in fast-paced, evolving environments and adapts quickly to changing client needs.</li><li>Applies strong clinical judgment and analytical reasoning.</li><li>Anticipates operational challenges, investigates root causes, and implements solutions.</li><li>Communicates effectively with clinical, operational, and client-facing stakeholders.</li><li>Champions operational efficiency and service excellence.</li><li>Provides ongoing feedback, mentorship, and professional development.</li></ul>Required Education &amp; Experience<ul><li>Active, unrestricted Registered Nurse (RN) license in California.</li><li>Minimum of 5 years of Utilization Management experience and 2 years of Appeals experience.</li><li>At least 2 years of leadership or supervisory experience in a UM or Appeals setting.</li><li>Strong understanding of UM and Appeals processes, including intake, screening, and documentation.</li><li>Experience managing or supporting remote clinical teams.</li><li>Familiarity with Medicare, Medicaid, and commercial payer requirements.</li><li>Excellent written communication, attention to detail, and organizational skills.</li><li>Ability to work independently during overnight and weekend shifts.</li></ul>Preferred Qualifications<ul><li>Bachelor of Science in Nursing (BSN).</li><li>Consulting or project-based healthcare experience.</li></ul>Work Schedule<ul><li>Day and overnight coverage, including:</li><li>Weekdays: 5:00 PM &ndash; 8:00 AM (PT)</li><li>Weekends: 8:00 AM Saturday &ndash; 8:00 AM Monday (PT)</li><li>Required holidays and on-call rotation.</li></ul>Physical Requirements / Work Environment<ul><li>Fully remote role with occasional travel (less than 5%).</li><li>Must maintain a secure home office environment with required equipment.</li><li>Prolonged periods of sitting and computer use.</li><li>Ability to communicate clearly in both written and verbal formats.</li></ul>Pay: $50.00 - $60.00 per hourBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Health insurance</li><li>Life insurance</li><li>Paid time off</li><li>Vision insurance</li></ul>Experience:<ul><li>Utilization management: 5 years (Required)</li><li>Appeals: 2 years (Required)</li><li>UM leadership : 2 years (Preferred)</li></ul>License/Certification:<ul><li>RN license in California? (Required)</li></ul>Shift availability:<ul><li>Day Shift (Required)</li><li>Night Shift (Required)</li><li>Overnight Shift (Required)</li></ul>Work Location: Remote

Supervisor, Utilization Management & Appeals (After-Hours/Overnight)

WellSense Health Plan

<div>It&rsquo;s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. 


Job Summary:

The Inpatient UM Clinical Supervisor is responsible for the daily supervision and operations of the Inpatient Utilization Management clinical team. Assigns work, ensures compliance with policies and procedures and is the first point of contact for complex issues to ensure cost effective utilization management of inpatient admissions. In collaboration with the UM Clinical Trainer/QA, trains newly hired staff and ensures that ongoing training needs of incumbents are met. Under the direction of the Manager of Clinical UM, uses available data to prioritize inpatient reviews including admission reviews, level of care reviews and continued stay reviews in acute and post-acute inpatient settings. Works closely with, and may share specific business goals with other clinical and non-clinical supervisor within UM to ensure and support integrated UM processes. 


Our Investment in You:
<ul><li> Full-time remote work</li></ul>
<ul><li> Competitive salaries</li></ul>
<ul><li> Excellent benefits</li></ul> 


Key Functions/Responsibilities:
<ul>
<li>Monitors and evaluates the quality, timeliness, and accuracy of inpatient UM reviews and discharge planning.</li>
<li>Under the guidance of the UM Director and Managers, employs recommended techniques to foster team work and staff development.</li>
<li>Uses subject matter expertise as well as knowledge of the interconnection between UM, claims, and regulatory requirements to respond to complex and/or escalated inquiries.</li>
<li>Utilizes critical thinking skills to identify process issues and problems, and recommend and/or implement solutions.</li>
<li>Under the direction of the UM managers, develops and uses metrics and management reports to monitor staff productivity, efficiency, and quality.</li>
<li>May identify workflow and systems improvements to enhance UM&rsquo;s ability to monitor, document, and improve key department performance indicators.</li>
<li>Ensures collaboration and integration with behavioral health care management, medical care management and social care management to ensure seamless transitions.</li>
<li>Collaborates with the Prior Authorization team and the care management team(s).</li>
<li>Participates in staff hiring, work allocation, training, performance management, including required documentation, as well as other supervisory functions under the guidance of the Manager of Clinical UM.</li>
<li>Assists with and participates in the planning, development, and implementation of department specific and cross functional projects.</li>
<li>Participates in maintaining accurate, consistent, updated department policies, procedures and workflows and related training materials.</li>
<li>In collaboration with the UM Clinical Trainer, is responsible for comprehensive orientation and ongoing training.</li>
<li>Uses the results of routine audits to monitor compliance with department standards and goals.</li>
<li>Provides high level of service and satisfaction to internal and external customers.</li>
<li>Responds to issues and concerns raised by staff and escalates to management as appropriate.</li>
<li>Other functions as required to support departmental activities.</li></ul> 


Supervision Exercised:
<ul>
<li>Directly supervises 5-15 staff.</li></ul> 


Supervision Received:
<ul>
<li>General supervision received weekly.</li></ul> 


Qualifications:

Education Required:
<ul>
<li>Bachelor&rsquo;s degree in Nursing or Associate&rsquo;s degree with relevant work
</li></ul>experience. 


Education Preferred:
<ul>
<li>Master&rsquo;s degree in Nursing, related clinical field or Health Care Administration is preferred.</li>
<li>CCM or Managed Care Certification.</li></ul> 


Experience Required:
<ul>
<li>One year of prior supervisory experience.</li>
<li>Two or more years in a managed care organization.</li>
<li>Three years related RN experience in an acute care facility or health insurance environment.</li></ul> 


Experience Preferred/Desirable:
<ul>
<li>Experience with inpatient utilization management strongly preferred.</li>
<li>Experience with CCMS and/or Jiva, or other utilization management system.</li>
<li>Experience with InterQual or other nationally recognized medical necessity criteria.</li>
<li>Experience with Medicaid/Medicare recipients and community services.</li></ul> 


Required Licensure, Certification or Conditions of Employment:
<ul><li>Successful completion of pre-employment background check</li>
<li>Active unrestricted state licensure as a Registered Nurse in the Commonwealth of Massachusetts</li></ul> 


Competencies, Skills, and Attributes:
<ul><li>Demonstrated ability to lead a team.</li>
<li>Strong oral and written communication skills; ability to interact within all levels of the organization.</li>
<li>Demonstrated comfort with ambiguity and change.</li>
<li>Demonstrated ability to create positive energy with individuals and groups.</li>
<li>Demonstrated ability to take action in solving problems while exhibiting sound judgement.</li>
<li>Strong organizational and time management skills.</li>
<li>Ability to work in a fast paced environment and multi-task.</li>
<li>A strong working knowledge of Microsoft Office applications.</li>
<li>Strong analytical and problem-solving skills.</li>
<li>Knowledge of analytics, metrics, and the ability to interpret data.</li>
<li>Demonstrated ability to successfully plan, organize and manage projects.</li>
<li>Detail oriented, excellent proof reading and editing skills.</li>
<li>Knowledge of process improvement techniques.</li></ul> 


Working Conditions and Physical Effort:
<ul><li>Regular and reliable attendance is an essential function of the position.</li>
<li>Work is normally performed in a typical interior/office work environment.</li>
<li>No or very limited physical effort required. No or very limited exposure to physical risk.</li>
<li>Travel to regional offices is required.</li></ul> 


Compensation Range

$88,500 - $128,500

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.
Note: This range is based on Boston-area data, and is subject to modification based on geographic location. 


About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. 


Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees</div>

Inpatient Utilization Management Clinical Supervisor

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