Utilization Review Nurse

About This Role

Performing utilization review to help reduce healthcare claim costs is the core of this nursing role. The position involves reviewing medical records, applying evidence-based guidelines, and collaborating with various parties to authorize or refer cases for physician review. It suits a nurse with strong clinical judgment and communication skills who is proficient with computer software.

Responsibilities

• Perform all aspects of the Utilization Review Process
• Review records and requests for UR, which may arrive via mail, e-mail, fax, or phone
• Utilize evidence-based guidelines to determine if authorization can be given versus having to send the file for Peer or Physician Review
• Write nurse summaries on all UR files
• Document properly in Rising's database (and client data bases when appropriate), and send determination letters on each completed UR
• Establish collaborative relationships with clients, patients, employers, providers and attorneys
• Track ongoing status of all UR activity so that appropriate turn-around times are met
• Maintain organized files containing clinical documentation of interactions with all parties of every claim
• Utilize good clinical judgment, careful listening, and critical thinking and assessment skills
• Respond to various written and telephonic inquiries regarding status of case
• Be proficient in the use of a computer, including the use of various software programs simultaneously

Requirements

• An Associate's or Bachelor's degree in Nursing
• Hold an active and unencumbered RN license in one or more states
• 3 to 5 years of clinical practice experience or 2 years of case management and/or UR experience
• Experience with Workers' Compensation, short-term or long-term disability, or liability claims
• The ability to set priorities and work both autonomously and as a team member
• Well-developed time-management, organization, and prioritization skills
• Excellent analytical skills
• Superb oral and written communication
• The ability to gather data, compile information, and prepare summary reports
• Strong interpersonal and conflict resolution skills
• Experience in a fast-paced, multi-faceted environment
• Demonstrated persistence and attention to detail
• General understanding of CPT and ICD-9/ICD-10 codes and Medicare guidelines
• Working knowledge of: Microsoft Word, Excel, and Outlook
• Ability to remain calm during stressful situations
• A customer-service mindset

Nice to have:

• More than one state license