RN Utilization Management remote - MediGold Health Plan

Why MediGold?

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. Were dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.

Position Purpose

RN Utilization Management MCHP is responsible for the coordination of the medical care provided to Plan members with Plan providers, the member's family and other resources as appropriate. Assist in the development of the Plan's UM Program and the review of the Plan's Utilization Management Plan.

What you will do

• Participates in designated committees and task forces according to the UM Program and at the direction of the Director, Utilization Management.
• Coordinates with the utilization review, case management, discharge planning staff within network facilities.
• Coordinates with Medical Director/Associate Medical Directors on case-specific issues.
• Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues.
• Documents and communicates to QM staff appropriately all identified quality concerns related to Members.
• All other duties as assigned.

Minimum Qualifications

• Education: Associate or Bachelor's Degree in Nursing
• Licensure / Certification: Current license to practice as a Registered Nurse in their home state or hold a compact nursing license.
• Experience: Minimum of 5-7 years of clinical nursing experience with at least 2 years experience in utilization review or case management. Nursing experience in an HMO insurance setting preferred Demonstrated ability to analyze, summarize and concisely report medical utilization and medical chart audit results.
• Ability to compare approved criteria with clinical information to determine appropriateness of service and to document all related information according to department policies and procedures.
• Conducts claim review as required for appropriate claims processing

Position Highlights and Benefits:

• Mount Carmel Health System recognized by Forbes in 2025 as one of Americas Best State Employers.
• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• RN to BSN tuition 100% paid at Mount Carmels College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• Mount Carmel offers DailyPay - if youre hired as an eligible colleague, youll be able to see how much youve made every day and transfer your money any time before payday. You deserve to get paid every day!
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

Ministry/Facility Information:

Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If youre seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided by all of us For All of You!

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.