RN Utilization Review

Sedgwick • St. David's, MI

1d

About The Position

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance RN Utilization Review PRIMARY PURPOSE: To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.

Requirements

• Strong clinical practice knowledge
• Ability to meet or exceed Performance Competencies
• Ability to work in a team environment
• Excellent negotiation skills
• Excellent interpersonal skills
• Strong organizational skills
• Analytical and interpretive skills
• PC literate, including Microsoft Office products
• Excellent oral and written communication, including presentation skills
• Knowledge of the insurance industry and claims processing
• Bachelor's or Associate degree from an accredited college or university preferred.
• Current unrestricted RN license in a state or territory of the United States required.
• Five (5) 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.

Nice To Haves

• Utilization review based certification strongly preferred.

Responsibilities

• Identifies treatment plan request(s) and obtains and analyzes medical records that support the reque
• 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.
• Performs other duties as assigned.
• Supports the organization's quality program(s

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree