RN-Medical Case Reviewer 2026-01345

State of Wyoming•Cheyenne, WY

9d•Onsite

About The Position

The Wyoming Department of Workforce Services is seeking a Nurse Case Manager to coordinate, evaluate, and monitor medical care services provided to injured workers receiving benefits under the Workers’ Compensation system. This position works closely with healthcare providers, employers, and division professionals to coordinate treatment plans and support injured workers in returning to their pre-injury level of functioning and employment. Responsibilities include evaluating claimant needs and medical records to direct medical case management activities and ensuring that appropriate medical care is delivered in compliance with division statutes, rules, regulations, and treatment guidelines. The position performs medical review screenings on pre-authorization requests for surgical procedures, obtains and reviews supporting medical documentation, and refers cases for peer review when indicated. Additional duties include documenting all interactions, reviews, approvals, and denials within the claims management system; reviewing CPT and ICD-10 codes and surgical descriptions for accuracy; and maintaining tracking systems for pre-authorizations, surgical procedures, clinical bills, and prescription requests. The Nurse Case Manager also reviews provider requests for compliance with treatment guidelines and serves as a medical resource for claims analysts by preparing medical questions for various evaluations. This position further reviews medical bills, prescription requests, urinalysis drug screens (UDS), chiropractic and physical therapy treatments, and durable medical equipment (DME) requests to determine medical relatedness and appropriateness of care.

Requirements

Must be licensed or eligible for licensure as a Registered Nurse (RN) in the State of Wyoming
Knowledge of community resources.
Skills in counseling and consultation.
Ability to apply principles of nursing, particularly medical terminology, and physical and psychosocial principles.
Ability to interpret diagnostic testing.
Ability to critically analyze data.

Responsibilities

Evaluate claimant needs and medical records to direct medical case management activities.
Provide assistance to healthcare providers, employers, and division professionals in coordinating care and treatment plans.
Ensure that appropriate medical care is delivered to injured workers in a manner that is consistent with the statutes, rules, and regulations of the division.
Perform a medical review screening on pre-authorization requests for proposed surgical procedures.
Obtain all medical documentation to accompany the pre-authorization requests.
Refer cases for peer review as indicated by treatment guidelines and medical reviews.
Document all interactions, reviews, approvals, and denials in the claims management system.
Review CPT and ICD-10 codes and surgical descriptions for accuracy on pre-authorization requests.
Review medical documentation utilizing the Division's treatment guidelines for surgical procedures.
Maintain tracking of all pre-authorization referrals, surgical procedures, clinical bills, and prescription requests.
Review pre-authorization provider requests for compliance with treatment guidelines.
Act as a medical resource for claims analysts; write medical questions for multiple types of evaluations.
Review medical bills, prescription requests, UDS, chiro/PT treatments, and DME for relatedness.