Utilization Review Nurse

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

📋 Description

• Conduct utilization reviews for Workers’ Compensation, encompassing prospective, concurrent, expedited, and retrospective evaluations.

• Assess the medical necessity and appropriateness of requested medical services based on evidence-backed criteria.

• Evaluate requests for inpatient, outpatient, surgical, and ancillary services.

• Analyze treatment requests in accordance with state regulations, ODG, evidence-based guidelines, and specific client authorization criteria.

• Review clinical data and, when necessary, escalate cases to a Peer Physician.

• Assess inpatient length of stay where relevant.

• Organize alternative care services and discharge planning; refer claimants to Case Management/TCM.

• Identify and assess potential safety concerns in collaboration with the Medical Director.

• Advocate for cost-effective healthcare through a connected provider network.

• Collaborate with Telephonic Case Management and Pharmacy TCM.

• Oversee determinations within the pharmacy portal.

• Execute NY PAR in the onboard system in accordance with NY MTG Guidelines.

• Fulfill productivity, time-management, quality assurance, billing, documentation, confidentiality, and company policy standards.

• Carry out other assigned responsibilities.

⛳️ Requirements

• A diploma, associate, bachelor's degree in nursing, or a master’s degree (or higher) in Nursing, Health, or Human Services, or equivalent relevant experience is preferred.

• A valid, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the applicable jurisdiction(s) is mandatory.

• Preference for candidates with interstate nurse compact licensure.

• Additional licensure may be required based on jurisdictional assignment.

• Preferred certifications include CCM, CMCN, CPHUR, CPDM, COHN, or CDMS.

• Must conduct reviews within state jurisdiction and URAC time limits.

• Uphold confidentiality and possess knowledge of laws and regulations related to HIPAA and PHI.

• Capable of light work and meeting specified visual, physical, and repetitive motion requirements.

🏝️ Benefits

• Medical, Dental, and Vision Insurance.

• Life and Disability Insurance.

• 401(k) Plan.

• Paid Holidays.

• Paid Time Off.

• Referral bonus.