Utilization Review Nurse

Tristar Insurance•Long Beach, CA

17h•$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 care using evidence-based criteria. Through discharge planning, the nurse identifies patients who may need ongoing case management and refers them to the Case Management team for outreach and follow-up. The role reviews treatment requests under applicable state guidelines, ODG and other evidence-based guidelines, and client-specific authorization criteria. It evaluates clinical information, determines medical necessity, and refers cases to a Peer Physician when appropriate. Reviews must be completed within state jurisdictional and URAC timeframes. The nurse also supports inpatient length-of-stay review, alternative care and discharge planning, coordination with case management and pharmacy teams, and management of determinations through designated systems. This is a full-time, remote position listed for all states. The stated salary range is $82,000–$88,000 per year. A current, unrestricted RN or LPN license recognized in the relevant jurisdiction(s) is required; additional licensure may be required based on assignment.

Requirements

Current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s).
Education in nursing, health, or human services, or equivalent related experience; the posting lists a diploma, associate, bachelor’s, or master’s-level (or higher) degree as possible education backgrounds.
Ability to meet applicable jurisdictional and URAC review timeframes.
Ability to meet productivity, time-management, Quality Assurance, documentation, billing, and confidentiality requirements.

Nice To Haves

Interstate nurse compact licensure is preferred.
CCM, CMCN, CPHUR, CPDM, COHN, or CDMS certification is preferred.
Additional relevant education or equivalent related experience is preferred.

Responsibilities

Conduct first-level prospective, concurrent, expedited, and retrospective utilization management reviews for inpatient and outpatient services, surgeries, and ancillary service requests.
Review treatment requests according to 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 jurisdictional and URAC timeframes.
Review inpatient length of stay when applicable.
Arrange alternative care services and discharge planning, and refer cases to telephonic case management as appropriate for service coordination.
Identify cases with potential safety issues and review them with the Medical Director.
Promote cost-effective healthcare 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 NY 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.
Meet 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.