RN Utilization Review

Sedgwick•Cincinnati, OH

5d•$73,000 - $75,000

About The Position

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance RN Utilization Review PRIMARY PURPOSE : To utilize evidence based tools to evaluate the prescribed medications to ensure patient safety and quality standards are in alignment with best practice standards. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. ESSENTIAL FUNCTIONS and RESPONSIBILITIES Performs clinical assessment via information in pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place. Evaluates patient drug usage and physician prescribing patterns. Evaluates overuse, underuse and misuse of prescribed medications and may recommend testing to determine if drug diversion is present. Evaluates need for and recommends alternative treatment. Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary. Negotiates appropriate level and intensity of care through use of medical and disability duration guidelines, adhering to quality assurance standards. Negotiates changes in pharmacy plan with providers. Acts as a resource in consulting with the client, nursing staff and claims examiners regarding pharmacy issues. Performs drug utilization reviews through the pharmacy benefit manager or vendor. Communicates effectively with claims examiner, client, vendor, supervisor and other parties as needed. Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards. ADDITIONAL FUNCTIONS and RESPONSIBILITIES Performs other duties as assigned. Supports the organization's quality program(s).

Requirements

Active unrestricted RN license in a state or territory of the United States required.
Four (4) years of related experience or equivalent combination of education and experience required to include two (2) years of direct clinical care OR two (2) years of case management/utilization management.
Knowledge of pharmaceuticals used to treat pain
Knowledge of behavioral health
Knowledge of pain management process
Knowledge of drug rehabilitation process
Knowledge of workers' compensation laws and regulations
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Leadership/management/motivational skills
Analytic and interpretive skills
Strong organizational skills
Excellent interpersonal skills
Excellent negotiation skills
Ability to work in a team environment
Ability to meet or exceed Performance Competencies

Nice To Haves

Bachelor's degree in nursing (BSN) from an accredited college or university or equivalent work experience preferred.
Certification in case management, pharmacy, rehabilitation nursing or a related specialty is highly preferred.

Responsibilities

Performs clinical assessment via information in pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place.
Evaluates patient drug usage and physician prescribing patterns.
Evaluates overuse, underuse and misuse of prescribed medications and may recommend testing to determine if drug diversion is present.
Evaluates need for and recommends alternative treatment.
Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary.
Negotiates appropriate level and intensity of care through use of medical and disability duration guidelines, adhering to quality assurance standards.
Negotiates changes in pharmacy plan with providers.
Acts as a resource in consulting with the client, nursing staff and claims examiners regarding pharmacy issues.
Performs drug utilization reviews through the pharmacy benefit manager or vendor.
Communicates effectively with claims examiner, client, vendor, supervisor and other parties as needed.
Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards.
Performs other duties as assigned.
Supports the organization's quality program(s).