Utilization Review Nurse

TRISTAR RISK MANAGEMENT•Long Beach, CA

2d•$82,000 - $88,000•Remote

About The Position

The Utilization Review Nurse performs Workers’ Compensation utilization reviews, including prospective, concurrent, expedited, and retrospective reviews, to determine the medical necessity and appropriateness of requested medical care using evidence-based criteria. Through discharge planning, the nurse identifies patients with ongoing case management needs and refers claimants to the Case Management team for outreach and follow-up. The position reviews treatment requests and clinical information against state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria. Reviews must comply with jurisdictional requirements and URAC timeframes. The nurse also supports inpatient length-of-stay review, alternative care arrangements, discharge planning, case management coordination, pharmacy determinations, and New York PAR processing. This is a full-time, remote position with a day shift. The listed salary range is $82,000 to $88,000 per year. The job description identifies light physical work and near- and mid-range vision requirements, as well as specified occasional and frequent physical activities.

Requirements

A current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required.
The candidate may be required to obtain additional licensure based on jurisdictional assignment.
Meet administrative requirements, including productivity, time management, and Quality Assurance standards.
Maintain confidentiality and comply with laws and regulations pertaining to HIPAA and PHI.

Nice To Haves

Diploma, associate, or bachelor’s degree in nursing, or a master’s-level or higher degree in a Nursing, Health, or Human Services field, or equivalent related experience is preferred.
Interstate nurse compact licensure is preferred.
CCM, CMCN, CPHUR, CPDM, COHN, or CDMS certification is preferred.

Responsibilities

Conduct first-level prospective, concurrent, expedited, and retrospective utilization management reviews of inpatient and outpatient services, surgeries, and ancillary service requests.
Review treatment requests in accordance with state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria.
Evaluate treatment requests and clinical information against treatment protocols and guidelines, identify medical necessity, and refer cases to a Peer Physician when appropriate.
Complete reviews within applicable state-jurisdiction and URAC timeframes.
Review inpatient length of stay when applicable.
Arrange alternative care services and discharge planning, and refer to Telephonic Case Management (TCM) as appropriate to coordinate services.
Identify cases with potential safety issues and review them with the Medical Director.
Promote cost-effective health care through an aligned health provider network.
Identify and refer cases to Telephonic Case Management or Pharmacy TCM.
Coordinate with TCM and Pharmacy TCM on appropriate next steps aligned with TCM goals.
Manage determinations within the pharmacy portal.
Perform New York PAR in the onboard system in accordance with NY MTG Guidelines.
Meet administrative requirements, including productivity, time management, and Quality Assurance standards.
Maintain template documentation standards in accordance with URAC standards and company policies and procedures.
Maintain minimum billing requirements and report billing hours in accordance with case activity and billing practices.
Maintain confidentiality and comply with laws and regulations pertaining to HIPAA and PHI.
Perform other duties as assigned.