RN Utilization Review

Sedgwick•Telecommuter OH, OH

2d•$73,000 - $75,000•Hybrid

About The Position

The RN Utilization Review role provides timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes. The position identifies treatment plan requests, obtains and analyzes supporting medical records, clarifies unclear requests with providers, and uses evidence-based criteria and jurisdictional guidelines to make utilization review determinations. When requests do not meet criteria, the role pursues Physician Advisor services and may negotiate treatment requests with providers when medically appropriate and jurisdictionally allowed. The RN documents outcomes in utilization review software, communicates clinical information to claim examiners as needed, maintains an internal audit score of at least 90%, and meets productivity goals set by the supervisor. The role requires an active, unrestricted RN license in a U.S. state or territory and an associate degree. A bachelor’s degree and utilization review certification are preferred. Applicants must have four years of related experience or an equivalent combination of education and experience, including recent clinical practice or utilization review experience. Sedgwick describes a blended work environment, ongoing learning and professional growth, meaningful work that promotes critical thinking and problem solving, and a supportive team culture. The posted starting pay range for the jurisdiction covered by the posting is $73,000–$75,000. A comprehensive benefits package is offered.

Requirements

Active, unrestricted RN license in a U.S. state or territory.
Associate degree from an accredited college or university.
Four years of related experience or an equivalent combination of education and experience.
Experience must include two years of recent clinical practice or one year of recent utilization review.
Ability to meet the role’s mental demands, including clear and conceptual thinking, judgment, troubleshooting, problem solving, analysis, discretion, handling work-related stress and multiple priorities, and meeting deadlines.
Ability to perform computer keyboarding.
Hearing, vision, and talking abilities.

Nice To Haves

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

Responsibilities

Identify treatment plan requests and obtain and analyze medical records supporting the requests.
Clarify unclear treatment plan requests by contacting the requesting provider’s office.
Use evidence-based criteria and jurisdictional guidelines to make utilization review determinations.
Pursue Physician Advisor services when treatment plan requests do not meet evidence-based criteria.
Negotiate treatment plan requests with requesting providers when medically appropriate and jurisdictionally allowed.
Channel certified treatment plan requests to preferred vendors as necessary.
Document utilization review outcomes in utilization review software.
Communicate and work with claim examiners as needed to provide clinical information and resolve issues.
Maintain a score of 90% or higher on monthly internal utilization review audits.
Meet productivity goals established by the supervisor.