Utilization Review Nurse

Acrisure•Bradenton, FL

1d•Hybrid

About The Position

Acrisure is seeking a Utilization Review Nurse, LPN to evaluate treatment requests and help ensure injured workers receive appropriate, timely care in accordance with applicable clinical guidelines and regulatory requirements. This role reviews medical information submitted by treating providers, determines whether treatment can be authorized at the nurse level, and refers requests for physician review when additional clinical evaluation is required. This position is ideal for an experienced LPN with a strong clinical background who enjoys applying their medical knowledge in an analytical, process-driven environment. Experience in utilization review or case management is highly beneficial, particularly within workers' compensation. Clinical experience involving orthopedic or neurological conditions is also highly valued. This is a hybrid position with two days per week in the office and three days remote. Candidates must also have flexibility to periodically work a later schedule to support business needs across multiple time zones.

Requirements

Active LPN license required
Active multistate/compact nursing license required
Strong clinical nursing experience with the ability to review medical records and evaluate treatment requests
Ability to interpret medical terminology, treatment plans, and clinical documentation
Ability to apply established clinical guidelines and determine when requests require physician review
Flexibility to periodically work later hours to support business needs across multiple time zones
Strong organizational skills with the ability to prioritize a high volume of time-sensitive reviews
Strong written and verbal communication skills
Proficiency with Microsoft Office applications and ability to learn new clinical and claims systems

Nice To Haves

Workers' compensation utilization review experience highly beneficial
Utilization review or case management experience highly beneficial
Clinical experience involving orthopedic or neurological conditions strongly preferred
Additional utilization review, case management, workers' compensation, or related professional certifications beneficial

Responsibilities

Review medical treatment requests and supporting clinical documentation for adherence to applicable state guidelines and utilization review requirements
Apply clinical knowledge and established guidelines to determine whether treatment requests can be authorized at the nurse level
Refer treatment requests requiring additional clinical evaluation to physicians for review
Evaluate medical records and treatment information to support timely and appropriate utilization review decisions
Complete required documentation and administrative processing throughout the utilization review process
Manage assigned reviews within applicable state-mandated and URAC turnaround requirements
Accurately document treatment requests, clinical information, review activity, and determinations within client records
Maintain confidentiality of medical and client information in accordance with HIPAA and applicable standards
Collaborate with physicians, healthcare providers, claims professionals, and internal team members to facilitate the review process
Maintain current clinical and industry knowledge relevant to utilization review and workers' compensation
Provide responsive service while managing multiple reviews and competing deadlines