RN Utilization Review
Apply NowLocation:
Dublin, OH, US
Company:
Sedgwick is the world’s leading risk and claims administration partner, providing unmatched perspective and solutions for navigating complex risk landscapes.
Summary:
The RN Utilization Review role involves providing evidence-based utilization review services for effective healthcare outcomes. Candidates are required to have an active RN license and relevant experience in clinical or utilization review settings.
Requirements:
Hard Skills: Strong clinical practice knowledge, Knowledge of the insurance industry and claims processing, Excellent oral and written communication, including presentation skills, Analytical and interpretive skills, Strong organizational skills, Excellent interpersonal skills, Excellent negotiation skills
Credentials: Active unrestricted RN license in a state or territory of the United States, Bachelor's or Associate degree from an accredited college or university preferred, Utilization review based certification strongly 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
Job Description:
RN Utilization Review
PRIMARY PURPOSE: To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.
ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.
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.
Education & Licensing
Active unrestricted RN license in a state or territory of the United States required. Bachelor's or Associate degree from an accredited college or university preferred. Utilization review based certification strongly 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
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
