[Hiring] Utilization Review RN @Sedgwick

Role Description

To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.

• 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.

Qualifications

• 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.
• 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.
• 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.

Requirements

• 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.

Benefits

• Work-life balance.
• Caring culture.