Buscar empleo: 78 ofertas de trabajo de nurse remote en Wichita, Kansas (junio 2026)

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

hace 7 días

Wichita

Job Description Job Overview Third-Party Administrator (TPA) We are seeking an experienced and compassionate Registered Nurse to join our team in a dynamic dual-role position combining Case Management and Utilization Review responsibilities within a Third-Party Administrator (TPA) environment. 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. Job tasks are performed telephonically; however, this is not a remote position. Applicant must be able to work on-site. Hours are Monday - Friday, 8:00 a.m. to 5 p.m. No on-call and no weekends Why Join Our Team • 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 Essential Responsibilities Case Management Responsibilities • 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 Utilization Review Responsibilities • 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 Reporting & Performance Metrics • 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 RequirementsRequired • 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 Preferred • 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 BenefitsCompensation & Benefits 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 If you are passionate about member advocacy, critical thinking, care coordination, and working as part of an innovative healthcare team, we encourage you to apply today.

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