RN Utilization Review

Sedgwick

20h•$73,000 - $75,000•Hybrid

About The Position

To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes. We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.

Requirements

Active unrestricted RN license in a state or territory of the United States required.
Associate degree from an accredited college or university required.
Four (4) years of related experience or equivalent combination of education and experience required to include two (2) years of recent clinical practice or one (1) year of recent utilization review.
Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Hearing, vision and talking

Nice To Haves

Bachelor’s degree from an accredited college or university preferred.
Utilization review based certification preferred.

Responsibilities

Identifies treatment plan request(s) and obtains and analyzes medical records that support the request.
Clarifies unclear treatment plan requests by contacting the requesting provider's office.
Utilizes evidence-based criteria and jurisdictional guidelines to form utilization review determinations.
Pursues Physician Advisor services when treatment plan requests do not meet evidenced-based criteria.
Negotiates treatment plan requests with requesting provider when medically appropriate and jurisdictionally allowed.
Channels certified treatment plan requests to preferred vendors as necessary
Documents all utilization review outcomes in utilization review software.
Communicates and works with claim examiners as needed to provide clinical information to resolve issues.
Maintains a score of 90% or higher on monthly internal utilization review audits.
Meets productivity goals as outlined by supervisor.