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Utilization Review RN PRIMARY PURPOSE : To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.
ESSENTIAL FUNCTIONS and 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.
ADDITIONAL FUNCTIONS and RESPONSIBILITIES
Performs other duties as assigned.
QUALIFICATIONS
Education & Licensing
Current unrestricted RN license in a state or territory of the United States required. Associate degree from an accredited college or university required. Bachelor’s degree from an accredited college or university preferred. Utilization review based certification preferred.
Experience
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.
Skills & Knowledge
Strong clinical practice knowledge
Knowledge of the insurance industry and claims processing
Excellent oral and written communication, including presentation skills
PC literate, 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
WORK ENVIRONMENT
When applicable and appropriate, consideration will be given to reasonable accommodations.
Mental: 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; and ability to meet deadlines
Physical: Computer keyboarding, travel as required
Auditory/Visual: Hearing, vision and talking
The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.