Utilization Review RN

Sedgwick•Telecommuter MI, MI

About The Position

The Utilization Review RN provides timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes. The role evaluates treatment plan requests and supporting medical records, applies evidence-based criteria and jurisdictional guidelines, coordinates with providers and Physician Advisors, and documents and communicates utilization review outcomes. The position also requires maintaining quality and productivity standards.

Requirements

Current unrestricted RN license in a state or territory of the United States.
Associate degree from an accredited college or university.
Four years of related experience or an equivalent combination of education and experience, including two years of recent clinical practice or one year of recent utilization review.
Strong clinical practice knowledge.
Knowledge of the insurance industry and claims processing.
Excellent oral and written communication, including presentation skills.
PC literacy, including Microsoft Office products.
Analytical and interpretive skills.
Strong organizational skills.
Excellent interpersonal skills.
Excellent negotiation skills.
Ability to work in a team environment.
Ability to meet or exceed Performance Competencies.

Nice To Haves

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

Responsibilities

Identify treatment plan requests and obtain and analyze supporting medical records.
Clarify unclear treatment plan requests by contacting the requesting provider's office.
Use evidence-based criteria and jurisdictional guidelines to make utilization review determinations.
Pursue Physician Advisor services when treatment plan requests do not meet evidence-based criteria.
Negotiate treatment plan requests with the requesting provider when medically appropriate and jurisdictionally allowed.
Channel certified treatment plan requests to preferred vendors as necessary.
Document all utilization review outcomes in utilization review software.
Communicate and work with claim examiners as needed to provide clinical information to resolve issues.
Maintain a score of 90% or higher on monthly internal utilization review audits.
Meet productivity goals as outlined by the supervisor.
Perform other duties as assigned.