Utilization Review Nurse

This is a fully remote position, open to applicants in California.

📋 Description

• Assess medical records to establish the medical necessity for requested healthcare services.

• Receive and evaluate treatment referrals for medical appropriateness in accordance with evidence-based guidelines and best practices.

• Identify medical diagnoses and treatment strategies; confirm diagnoses and corresponding care algorithms.

• Review treatment protocols and provide recommendations utilizing MTUS, ACOEM, MCG, ODG, state-specific treatment guidelines, and provider documentation.

• Analyze over-utilization and negotiate with providers to modify or rescind inappropriate treatment requests when feasible.

• Forward potential non-certification cases to peer clinical reviewers and facilitate peer-to-peer communication as necessary.

• Guide and optimize the use of PPO/MPN networks.

• Pre-authorize suitable inpatient and outpatient procedures.

• Relay utilization review decisions to claims examiners, providers, attorneys, and auxiliary providers within mandated state time frames, followed by written communication within 24 hours.

• Summarize medical records and relevant information with recommendations for the Physician Advisor, or prepare inquiries for peer or third-party review.

• Recognize the necessity for medical case management and propose referrals through the supervisor.

• Collaborate closely with clients, claims handlers, nurse case managers, and supervisors.

• Supervise availability and oversee non-clinical staff activities and assigned responsibilities.

• Assist with notifications regarding non-certifications issued by physician-reviewers.

⛳️ Requirements

• At least 3 years of clinical experience.

• Desired experience in California Worker’s Compensation, Managed Care, and Utilization Review.

• Knowledge of California Worker’s Compensation regulations.

• Familiarity with medical terminology.

• Completion of IEA CA10 is mandatory within the first year of employment.

• A solid understanding of the workers’ compensation system is essential.

• May need to oversee ancillary non-licensed personnel.

• Self-driven with the ability to manage multiple tasks and adjust to shifting work priorities.

• Strong organizational abilities with a keen attention to detail.

• Excellent time management skills.

• Capability to work with a diverse range of clients and providers.

• Ability to follow instructions accurately.

🏝️ Benefits

• Extensive medical, dental, and vision coverage.

• Company contributions to HSA and FSA plans.

• Employer-paid life and disability insurance.

• 401(k) plan with company matching.

• Paid time off (PTO) and company-recognized holidays.

• Opportunities for learning and development that promote genuine career advancement.

• Access to employee assistance resources.

• A supportive culture that emphasizes balance and well-being.

• Additional training provided.