Clinical Care Manager- Utilization Review Nurse

About the position 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.

Responsibilities

• Complete timely review of healthcare services using appropriate medical criteria to support determinations.
• Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
• Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
• Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality‑of‑care review.
• Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives.
• Identify and refer eligible members to disease management programs to enhance care quality and continuity.
• Manage and document on‑call phone communications with members and providers on a rotational basis.
• Maintain confidentiality of all member information and case records.
• Participate in quality management initiatives and support related documentation, reporting, data collection, and committee activities.
• Prepare benefit exhaustion letters upon request.
• Assist with the design and maintenance of clinical and/or client-specific reports, spreadsheets, and analyses.
• Maintain current knowledge of relevant regulations, multi‑jurisdictional requirements, medical group guidelines, and URAC standards.
• Maintain ongoing professional education and growth aligned with Illinois nursing regulations and contemporary clinical practice.

Requirements

• Active, unrestricted Registered Nurse (RN) license in Illinois.
• 5+ years of experience across varied healthcare settings.
• Knowledge of utilization review, managed care processes, and community health.
• Meets Illinois CE requirement of 20 hours per 2‑year RN license renewal cycle .
• Strong proficiency in Microsoft 365 (Word, Excel, PowerPoint, etc.).
• Excellent written, verbal, and organizational skills.
• Ability to prioritize effectively amid rapidly changing business needs.
• Demonstrates strong clinical judgment, compassion, and a positive attitude.

Nice-to-haves

• Advanced degree or certification in Case Management , Utilization Review , and/or Quality .
• Interest in Clinical Informatics .
• Knowledge of Population Health and Health Disparities .
• Previous experience in health insurance or managed care settings.

Benefits

• 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.
• Keep Health a Priority: We offer comprehensive Medical, Dental, and Vision plans to keep you covered.
• Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
• 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.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
• 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.
• 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.

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