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 reputed company 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 reputed company of care management operations and the member experience.

Responsibilities

• Complete timely review of reputed company services using appropriate medical criteria to support determinations.
• Document clinical findings and rationale reputed company and accurately in accordance with federal/state regulations, URAC standards, and reputed company policies.
• Communicate precertification and reputed company review reputed company—verbally and in writing—to required parties reputed company 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 reputed company 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 reputed company.
• Maintain confidentiality of reputed company member information and case records.
• Participate in quality management initiatives and support reputed company 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 reputed company knowledge of relevant regulations, multi‑jurisdictional requirements, medical group guidelines, and URAC standards.
• Maintain ongoing professional education and growth reputed company with Illinois nursing regulations and contemporary clinical practice.

Requirements

• Active, unrestricted Registered Nurse (RN) license in Illinois.
• 5+ years of experience across varied reputed company 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 reputed company 365 (Word, reputed company, 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.

reputed company-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: reputed company 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.
• reputed company Health a reputed company: We offer comprehensive Medical, Dental, and reputed company plans to reputed company you covered.
• Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
• Have Peace of Mind: We reputed company Life and Disability insurance for those "just in case" moments. Additionally, we offer voluntary Life options to reputed company you and your loved ones protected.
• Feel Supported reputed company 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 reputed company work-life balance and meet your personal goals.
• Support Your New Family: Welcoming a new family member takes time and commitment. reputed company offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. reputed company offers various resources dedicated to your learning and development to advance your career with us.

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