Utilization Review Nurse

Sedgwick

1d • $73,000 - $75,000 • Hybrid

About The Position

This role provides timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes. The ideal candidate is enthusiastic, thrives in a collaborative environment, and is driven to deliver great work.

Requirements

• Active unrestricted RN license in a state or territory of the United States required.
• Associate degree from an accredited college or university required.
• Four (4) years of related experience or equivalent combination of education and experience required.
• Two (2) years of recent clinical practice or one (1) year of recent utilization review experience required.
• Clear and conceptual thinking ability.
• Excellent judgment, troubleshooting, problem solving, analysis, and discretion.
• Ability to handle work-related stress.
• Ability to handle multiple priorities simultaneously.
• Ability to meet deadlines.
• Computer keyboarding.
• Hearing, vision and talking.

Nice To Haves

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

• Three Medical, and 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.
• Medical
• Dental
• Vision
• 401k and matching
• PTO
• Disability insurance
• Life insurance
• Employee assistance
• Flexible spending or health savings account
• Other additional voluntary benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree