RN Utilization Management remote

Why MediGold?

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We're dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

Position Purpose

RN Utilization Management MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member's family and other resources as appropriate. Assist in the development of the Plan's UM Program and the review of the Plan's Utilization Management Plan.

What you will do

• Participates in designated committees and task forces according to the UM Program and at the direction of the Director, Utilization Management.
• Coordinates with the utilization review, case management, discharge planning staff within network facilities.
• Coordinates with Medical Director/Associate Medical Directors on case-specific issues.
• Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues.
• Documents and communicates to QM staff appropriately all identified quality concerns related to Members.
• All other duties as assigned.

Minimum Qualifications

• Education: Associate or Bachelor's Degree in Nursing
• Licensure / Certification: Current license to practice as a Registered Nurse in their home state or hold a compact nursing license.
• Experience: Minimum of 5-7 years of clinical nursing experience with at least 2 years' experience in utilization review or case management. Nursing experience in an HMO insurance setting preferred· Demonstrated ability to analyze, summarize and concisely report medical utilization and medical chart audit results.
• Ability to compare approved criteria with clinical information to determine appropriateness of service and to document all related information according to department policies and procedures.
• Conducts claim review as required for appropriate claims processing

Position Highlights and Benefits:

• Mount Carmel Health System recognized by Forbes in 2025 as one of America's Best State Employers.
• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings