Registered Nurse (RN) - Case Manager & Utilization Review Nurse

Job Overview

This role is ideal for an RN who enjoys applying clinical expertise in a collaborative, non-bedside setting while supporting quality member outcomes, appropriate utilization of healthcare services, and effective care coordination. The nurse will work closely with providers, members, facilities, pharmacy benefit managers (PBMs), stop-loss carriers, insurance brokers, and health plan partners to ensure medically appropriate, cost-effective, and member-centered care.

The ideal candidate is a collaborative and self-directed RN who thrives in a fast-paced managed care environment and enjoys integrating member advocacy with clinical review responsibilities. Successful candidates are adaptable, solutions-focused, data-driven, and committed to delivering high-quality, efficient care coordination and utilization management services while supporting positive member experiences and cost-effective healthcare outcomes.

• Opportunity to utilize both clinical and analytical nursing skills in one integrated role
  
• Collaborative environment with providers, healthcare partners, PBMs, brokers, stop-loss carriers, and interdisciplinary teams
  
• Meaningful work focused on improving member outcomes, continuity of care, and healthcare affordability
  
• Professional growth opportunities in case management, utilization review, and managed care
  
• Predictable schedule and improved work-life balance compared to bedside nursing
  
• Supportive leadership and team-oriented culture
  
• Ability to impact member experience directly, care quality, and healthcare efficiency
  

• Coordinate and monitor member care plans across the continuum of care
  
• Communicate with providers, facilities, members, caregivers, brokers, and health plan partners to facilitate appropriate treatment and services
  
• Assist members in accessing in-network providers, facilities, and services to support cost-effective, coordinated care
  
• Collaborate with Pharmacy Benefit Managers (PBMs) and specialty pharmacies regarding members receiving specialty medications, including care coordination, adherence support, and medication access
  
• Follow up with members participating in wellness and care management programs to encourage engagement, monitor progress, and support health goals
  
• Identify barriers to care and assist in coordinating resources to support optimal member outcomes
  
• Facilitate transitions of care and discharge planning as appropriate
  
• Educate members regarding treatment plans, healthcare resources, preventive services, and care options
  
• Collaborate with stop-loss carriers regarding high-cost claims, large case management opportunities, and clinical updates as appropriate
  
• Communicate and coordinate with insurance brokers regarding member care initiatives, wellness engagement, and case management activities when applicable
  
• Maintain accurate and timely documentation in accordance with company policies and regulatory requirements
  

• Perform prospective, concurrent, and retrospective utilization reviews to assess medical necessity, appropriateness of care, and level of service
  
• Review clinical documentation and treatment requests using established evidence-based criteria and payer guidelines
  
• Apply utilization review criteria such as payer-specific standards
  
• Communicate with providers regarding authorization requirements, clinical information requests, and review determinations
  
• Ensure compliance with payer policies, accreditation standards, and regulatory requirements
  
• Assist in reducing unnecessary utilization and healthcare costs through proactive clinical review and care coordination
  
• Support denial prevention efforts through accurate documentation review and timely follow-up
  
• Participate in quality improvement initiatives and interdisciplinary case discussions
  
• Assist with identification and monitoring of high-cost claims and cases with potential stop-loss exposure
  

• Track, monitor, and report key performance indicators (KPIs) related to case management, utilization review, wellness engagement, turnaround times, member outcomes, and cost containment initiatives
  
• Maintain productivity and quality benchmarks established by the organization
  
• Assist leadership with identifying trends, opportunities for process improvement, and utilization patterns
  
• Prepare reports and clinical summaries for internal stakeholders, stop-loss carriers, and broker partners as needed
  

• Current, unrestricted Kansas or Multi-state Registered Nurse (RN) license
  
• Minimum of 4 years of clinical nursing experience
  
• Strong clinical assessment and critical thinking skills
  
• Excellent communication and interpersonal abilities
  
• Strong organizational skills and attention to detail
  
• Ability to manage multiple priorities in a fast-paced environment
  
• Proficiency with electronic medical records and clinical documentation systems
  

• Previous experience in:
  
  • Case Management
    
  • Utilization Review
    
  • Managed Care
    
  • TPA Environment
    
  • Health Plan or Insurance Setting
    
• Experience working with PBMs, specialty medications, wellness programs, or chronic disease management programs
  
• Experience collaborating with stop-loss carriers or insurance brokers preferred
  
• BSN preferred
  

We offer a competitive compensation and benefits package including:

• Medical and dental insurance
  
• Paid time off
  
• Employee Assistance Program
  
• Flexible Spending Account
  
• Retirement plan options