Utilization Management RN

Who We Are

WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready.

Culture Drives Our Success

WPS’ Performance-Based Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an inclusive and empowering employee experience. We recognize the benefits of Diversity, Equity, and Inclusion as an investment in our workforce—both current and future—to effectively seek, leverage, and include diverse perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

From 2021 to 2023, WPS Health Solutions was recognized for several awards:

Madison, Wisconsin’s Top Workplaces
USA Top Workplaces and the cultural excellence awards for Remote Work and Work-Life Flexibility
Achievers 50 Most Engaged Workplaces® with the further honor of Achievers “Elite 8” winner in the category of Culture Alignment
DAV Patriot Employer
VETS Indexes 4 Star Employer
BBB Torch Award for Ethics from Better Business Bureau of Wisconsin

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. You will be part of a high performing 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:

You are an excellent communicator and have extensive experience working with and having empathy for a diverse number of internal and external customers
Proven strong analytical and problem-solving skills
You have a track history of working within several electronic platforms (electronic medical record systems, utilization management systems, claims systems, etc.).
You are responsible to keep current with medical knowledge and technical advances in the health care industry.
Strong ability to use judgement to educate customers or providers, and problem-solve unique customer issues and circumstances for a variety of conditions and problems.
Familiarity with MCG criteria and Utilization Management Platforms (e.g. Medecision-Aerial).
Knowledge of Wisconsin providers and care systems.
Maintains confidentially of customer and case information by following corporate privacy policies.
Strong set of change management skills; which involves accepting, supporting, and executing assignments in conditions of change which support attaining department goals.

What will I gain from this role?

The opportunity to partner with WPS Medical Directors to evaluate services being requested
Experience working with medical policies, medical criteria, and authoritative resources
Knowledge by being exposed to a large variety of healthcare situations and medical conditions
The ability to work in a high-touch team environment
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)