Utilization Review Nurse

Please make sure to complete all the questions in the application and continue through to the end in order to sign and submit it.

The preferred work hours are 8:30 am / 9 am - 5 pm / 5:30 pm central time zone.

Responsible for performing Workers’ Compensation utilization review, which includes prospective, concurrent, expedited, and retrospective reviews to determine medical necessity and appropriateness for requested medical care using evidence-based criteria. Through the discharge planning process, identify patients with ongoing case management needs and refer these claimants to the Case Management team for outreach and follow-up.

Essential Duties and Responsibilities:

Conducts first-level prospective, concurrent, expedited, and retrospective utilization management, including inpatient services, outpatient services, surgeries, and ancillary service requests

Reviews of all requests for treatment in accordance with specific state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria

Evaluate treatment requests and review clinical information received with treatment protocols and guidelines, identify medical necessity, and refer to Peer Physician when appropriate. Reviews must be conducted within state jurisdiction and URAC time frames.

Review length of stay for inpatient cases when applicable

Arrange alternative care services/discharge planning and refer to TCM as appropriate for coordinating of services

Identify & review with Medical Director any case with potential safety issues

Promote cost-effective health care with an aligned health provider network

Identify and refer to Telephonic Case Management / Pharmacy TCMCoordinate with TCM / Pharmacy TCM to achieve appropriate next steps which align with TCM goals

Manage determinations within the pharmacy portal

Perform NY PAR in the onboard system in accordance with NY MTG Guidelines Additional Functions and Responsibilities Demonstrates ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards

Maintain established template documentation standards adhering to URAC standards and company policies and procedures

Maintain minimum billing and report billing hours in accordance with case activity and billing practices

Maintain confidentiality - knowledge of laws and regulations pertaining to HIPPA and PHIOther job duties as assigned

Education:

Diploma, Associate, bachelor’s degree in nursing, or Master’s level (or higher) degree in a Nursing, Health or Human Services field, or equivalent related experience preferredA current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required. Interstate nurse compact licensure is preferred. The candidate may be required to obtain additional licensure based on jurisdictional assignment.

CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred

Here are some of the benefits you can enjoy in this role:

Medical, Dental, Vision Insurance.

Life and Disability Insurance.
401(k) Plan Paid Holidays Paid Time Off.

Referral bonus.

Mental and

Physical Requirements:

[see separate attachment for a copy of checklist of mental and physical requirements]MENTAL AND

PHYSICAL REQUIREMENTS
1. MENTAL EFFORTa. Reasoning development:

Follow one- or two-step instructions; routine, repetitive task.

Carry out detailed but uninvolved written or verbal instructions; deal with a few concrete variables.

Follow written, verbal, or diagrammatic instructions; several concrete variables.

X Solve practical problems; variety of variables with limited standardization; interpret instructions.

Logical or scientific thinking to solve problems; several abstract and concrete variables.

Wide range of…