Utilization Review Nurse

ESSENTIAL RESPONSIBILITIES

Review complex workers compensation medical treatment requests to ensure accordance with evidence-based medical treatment guidelines, which are generally recognized by the national medical community and are scientifically based.

Research claim file in relation to the requested medical treatment while interpreting medical reports/claims summaries and applies appropriate established guidelines to requested treatment. Refers treatment requests, which do not meet guidelines, for peer review and determination.

Advocate for the injured worker and claims department, ensuring proposed treatment requests are appropriate for the diagnosis.

Performs daily tasks within the appropriate established workflow processes, utilizes accepted guidelines and meets legislative and departmental timeframes.

Maintain patient confidentiality in discussions of treatment, disease process and conditions.

Routinely contacts providers to clarify treatment requests, examination findings, as well as obtain additional medical information as needed.

Maintains clear, concise, and accurate documentation of requested medical treatments to include clinical findings, treatment guidelines, and determination.

Provide appropriate notices to providers, injured workers, claims staff, and attorneys.

Act as a medical resource in regards to utilization review to Claims Support Nurse, Bill Review, and Claims department.

Foster a positive and close working relationship with other Company staff, including the claims staff, medical bill review, claims support nurse, special investigations, legal, liens, the call center, and client services.

Communicate effectively with individuals outside the company, including clients, medical providers, and vendors.

WHAT WILL SET YOU APART

EDUCATION: Bachelor of Science Nursing degree (BSN), or Registered Nursing degree (RN) from four-year college or university, or an accredited college.

LICENSES/EXPERIENCE: A current RN license as well as 5+ years of recent, hands-on clinical experience in a Critical care unit such as Medical Surgery, Emergency Room, ICU, Oncology, Orthopedics, Neuro or other similar settings. Must have an active state license and eligible to obtain additional state licenses.

TECHNICAL SKILLS: Knowledge of current recognized evidence-based medicine guidelines required. Proficient in Microsoft Office suite of applications. Able to perform independent internet medical research. Able to quickly master proprietary and vendor software applications.

LANGUAGE ABILITY: Able to read, analyze, and interpret common scientific and technical journals, statutes, regulations, medical reports, medical coding, medical bills, financial reports, and legal documents. Able to respond to technical inquiries or complaints from Company employees, external sources, and regulatory or auditing entities.

REASONING ABILITY: Able to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Able to deal with problems involving several concrete variables in standardized situations.

WHAT WE OFFER

Work From Home (Up to 2 days per week upon eligibility)

Onsite Gym

Garage Parking

Within walking distance of the Old Market District

Paid Time Off

Paid Holidays

Retirements Savings Match

Group Health Insurance (Medical, Dental, and Vision)

Life and AD&D Insurance

Long Term Disability Insurance

Paid Community Volunteer Day

Employee Assistance Program

Tuition Reimbursement Program

Employee Referral Program

Diversity, Equity and Inclusion Program