Role Snapshot 

In this role you will become a thoughtful steward of our members healthcare benefits by evaluating the efficiency, appropriateness, and medical necessity of medical services, procedures, and facilities. This is done by reviewing evidence-based criteria and jurisdictional guidelines to make final determinations regarding medical necessity. You will be part of a growing team and will have the opportunity to evaluate medical care across the entire continuum of care.

How do I know this opportunity is right for me? If you: 

• Are familiar with MCG criteria and Utilization Management Platforms (e.g., Medecision-Aerial).
• Have strong analytical, critical thinking and problem-solving skills.
• Have strong communication skills and willingness to consult with our medical directors on difficult cases.
• Have experience working within several electronic platforms (electronic medical record systems, utilization management systems, claims systems, etc.).
• Keep current with medical knowledge and technical advances in the health care industry.
• Excel at using independent judgement to educate customers or providers, and problem-solve unique customer issues for a variety of conditions and problems.
• Possess strong change management skills which include accepting, supporting, and executing assignments in conditions of change which support department goals.

What will I gain from this role?

• The opportunity to partner with Medical Directors in decision making.
• Exposure to a large variety of healthcare situations and medical conditions.
• Experience working for a company that serves our nation’s military, veterans, Guard and Reserves, and Medicare beneficiaries.
• Working in a continuous performance feedback environment.

Minimum Qualifications

• Bachelor of Science Degree in Nursing
• 1 or more years of related work experience
• Active license as an RN in the State of Wisconsin or a valid multi-state compact license
• Must maintain license after hired

Preferred Qualifications

• 5 or more years of experience as an RN in a varied clinical setting (hospital, clinic, home care, skilled nursing facility, etc.) with 2 or more years in some component of Managed Care (case management, disease management, prior authorization, utilization review, or quality assurance).
• Working knowledge of knowledge of CPT/ICD 10/HCPCS codes.
• Health insurance background in a Health Maintenance Organization (HMO), Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Advantage (MA) plans.

Remote Work Requirements

• Wired (ethernet cable) internet connection from your router to your computer
• High speed cable or fiber internet
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)

Salary Range 

$75,000 - $100,000

The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

Work Location

We are a remote-first organization and offer remote work in the following approved states:

Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, Wisconsin