Job Description

Utilization Review Nurse for Workers' Compensation - Injured Workers

Job Purpose:
Review Workers Compensation requests submitted by the provider, requestor, claimant or carrier to determine the medical necessity of the treatment utilizing clinical expertise and evidence-based treatment guidelines.

Duties:

• Perform an evaluation of the medical data for utilization review requests.
• Confirm accurate completion of data intake.
• Collect additional relevant data as needed with regard to determining medical necessity.
• Analyze the collected data to apply evidence-based guidelines.
• Review requests and make certification decisions, when appropriate, or prepare a case for peer review referral.
• Coordinates information between all parties (injured worker, physicians, employer, therapists, attorney, etc)
• Participate in audits of work product to ensure compliance.
• Monitor daily processing inventory, including rush/urgent requests.
• Provide inventory information and raise concerns to clinical director.
• Complete production logging.
• Assist leadership team with training and coordinating back-up resources.

Requirements/Skills/Qualifications:

• Graduate of an accredited school
• Valid current RN license in good standing
• Able to perform the professional and technical skills of a Registered Nurse
• Minimum 2 years of direct patient care
• Excellent, written and oral communication skills
• Ability to read and interpret medical reports and treatment guidelines
• Must be able to maintain confidentiality
• Must possess strong personal organizational skills
• Must have experience and knowledge of intermediate computer skills
• Ability to work independently with little to no supervision
• Ability to work in a fast-paced and time-sensitive environment
• Ability to meet deadlines in a production driven environment
• Ability to work with WORD and EXCEL documents.

Preferences:

• Experience in Utilization Review, Workers Compensation is a plus

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