Utilization Review Nurse Case Manager
About The Position
The Utilization Review Nurse is responsible for applying medical knowledge, judgment, jurisdictional rules, and medical treatment guidelines to review workers’ compensation medical necessity reviews. The Utilization Review (UR) Nurse engages with physicians, peer reviewers and collaborates with claim handlers to determine appropriate treatment decisions. The UR Nurse must be able to demonstrate and be accountable for the standards of practice, policies and procedures, quality assurance, and the goals of the organization. Also, review treatment of claimants through the workers’ compensation system based on the individual’s diagnosis, and jurisdictional regulations. Review medical records and treatment plans to determine medical necessity and appropriateness of medical treatment based upon established guidelines, and jurisdictional rules. Conduct prospective, concurrent, and retrospective medical necessity reviews. Apply standardized and appropriate clinical guidelines and document claim file to justify treatment approvals. Issue pre authorizations for procedures, diagnostic tests, therapies, and equipment. Collaborate with physicians and healthcare providers to clarify treatment requests. Communicate with claims handlers regarding treatment decisions, utilization trends, and determinations. Ensure UR processes comply with state workers' compensation guidelines and regulatory bodies. Maintain timely and accurate documentation that complies with regulatory and URAC requirements. Stay updated on changes in healthcare policies and workers’ compensation rules. Prepare and submit clinical appeals when treatment requests are denied, supporting medical necessity with proper documentation.
Requirements
- Registered nurse license active and unrestricted required.
- Bachelor’s degree in nursing (BSN) preferred.
- Compact and or multiple state RN licenses, or the ability to obtain additional licenses.
- Five (5) years of active patient or clinical care experience as a Registered Nurse is required.
- Three (3) years workers compensation case management/utilization review, occupational health, rehabilitation or insurance experience preferred.
- Excellent oral and written communication skills.
- Demonstrated leadership and project management abilities.
- Ability and proficiency in the use of computers and Company standard software specific to position, including Microsoft Office products.
- Strong clinical assessment, critical thinking, and communication skills.
- Expertise in evidenced based guidelines.
- Ability to analyze utilization data and identify trends.
- Knowledge of clinical care and jurisdictional requirements.
- Demonstrates the ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
- Demonstrates use of critical thinking, attention to detail, sound clinical judgement and assessment for decision making.
- Demonstrates courteous, professional demeanor, ability to work collaboratively within a team and independently.
- Strong working knowledge of workers’ compensation laws.
- Must possess strong negotiation skills and decision-making ability.
- Attention to detail and analytical skills required.
- Ability to exercise good judgement in evaluating and determining appropriateness of various actions within the process of workers compensation claims.
- Ability to make competent, independent decisions and maintain confidentially where appropriate.
Nice To Haves
- Bachelor’s degree in nursing (BSN) preferred.
- Three (3) years workers compensation case management/utilization review, occupational health, rehabilitation or insurance experience preferred.
Responsibilities
- Apply medical knowledge, judgment, jurisdictional rules, and medical treatment guidelines to review workers’ compensation medical necessity reviews.
- Engage with physicians, peer reviewers and collaborate with claim handlers to determine appropriate treatment decisions.
- Demonstrate and be accountable for the standards of practice, policies and procedures, quality assurance, and the goals of the organization.
- Review treatment of claimants through the workers’ compensation system based on the individual’s diagnosis, and jurisdictional regulations.
- Review medical records and treatment plans to determine medical necessity and appropriateness of medical treatment based upon established guidelines, and jurisdictional rules.
- Conduct prospective, concurrent, and retrospective medical necessity reviews.
- Apply standardized and appropriate clinical guidelines and document claim file to justify treatment approvals.
- Issue pre authorizations for procedures, diagnostic tests, therapies, and equipment.
- Collaborate with physicians and healthcare providers to clarify treatment requests.
- Communicate with claims handlers regarding treatment decisions, utilization trends, and determinations.
- Ensure UR processes comply with state workers' compensation guidelines and regulatory bodies.
- Maintain timely and accurate documentation that complies with regulatory and URAC requirements.
- Stay updated on changes in healthcare policies and workers’ compensation rules.
- Prepare and submit clinical appeals when treatment requests are denied, supporting medical necessity with proper documentation.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
