Utilization Review Nurse
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. The primary purpose of the Utilization Review Nurse is to provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes. Sedgwick is the world’s leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company’s expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape.
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 recent clinical practice OR one (1) year of recent utilization review.
Nice To Haves
- Bachelor's or Associate degree from an accredited college or university preferred.
- Utilization review based certification strongly 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.
Benefits
- Offering a blended work environment.
- Supporting meaningful work that promotes critical thinking and problem solving.
- Providing on-going learning and professional growth opportunities.
- Promoting a strong team environment and a culture of support.
- Recognizing your successes and celebrating your achievements.
- Thrives when everyone is working towards the same vision/goals.
- Three Medical plans to choose from.
- Two dental plans to choose from.
- Tuition reimbursement eligible.
- 401K plan that matches 50% on every $ you put in up to the first 6% you save.
- 4 weeks PTO your first full year.
- Vision insurance.
- Disability and life insurance.
- Employee assistance.
- Flexible spending or health savings account.
- Other additional voluntary benefits.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
251-500 employees
