Clinical Care Manager Utilization Review Nurse

Overview

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.

• 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 time frames.

• 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.

• 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.

• 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.

All your information will be kept confidential according to EEO guidelines.

At Guidehealth, our values come to life in everything we do.

• We are Driven by Accountability — grounded in transparency, reliability, and integrity as we navigate challenges and opportunities alike.
• Always Growing, Always Learning — staying curious and continuously improving inspires us to shape a better future for healthcare.
• With Collaborative Innovation, we solve problems creatively, making every experience better for our employees and the patients we serve.
• At Guidehealth, Every Voice Matters — we believe our collective strength is rooted in the unique perspectives of each team member.
• And through Empathy in Action, we build stronger connections with those who count on us.
• This is what it means to be ALIVE with purpose. This is how we thrive — together — at Guidehealth.

• Work from Home:
  Guidehealth is a fully remote company, providing you the flexibility to spend less time commuting and more time focusing on your…