About the role
Guidehealth, a value-based care company, is hiring a remote Utilization Management RN to run precertification and concurrent reviews for its Illinois-based provider network. You'll apply medical necessity criteria, document determinations to regulatory standard, and work directly with the Medical Director on complex cases — while also helping shape how AI tools get used in the review workflow.
Responsibilities
- Complete timely precertification and concurrent reviews using approved medical necessity criteria
- Document clinical findings, criteria applied, and review determinations to meet regulatory and accreditation (URAC) standards
- Communicate review outcomes to providers, members, and other parties within required turnaround times
- Partner with the Medical Director and peer reviewers on medical necessity, treatment plans, and quality-of-care questions
- Coordinate with ordering providers and, when appropriate, members or their representatives directly
- Give feedback on AI tools used in daily review work to help improve them
- Refer patients into disease management or population health programs where appropriate
- Support UM/population-health committee reporting and trend analysis for assigned provider groups
Requirements
- Active, unrestricted Illinois RN license (no compact license substitute for this role)
- 3+ years of nursing experience across varied healthcare settings
- Working knowledge of utilization review, managed care, and community health
- Comfortable meeting Illinois' 20-CE-hour / 2-year license renewal requirement
- Proficient in Microsoft 365 (Word, Excel, PowerPoint)
- Strong clinical judgment plus clear written and verbal communication
What we offer
- Fully remote role
- Medical, dental, and vision coverage
- 401(k) with 3% employer match on a 6% employee contribution
- Life and disability insurance, with optional voluntary life coverage
- Employee Assistance Program
- Paid time off and paid parental leave
- Professional development support
- Company-provided equipment