Utilization Review Nurse (RN)

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance Utilization Review Nurse (RN) 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. ADDITIONAL FUNCTIONS and RESPONSIBILITIES Performs other duties as assigned. QUALIFICATIONS Education & Licensing Active unrestricted RN license in a state or territory of the United States required. Associate degree from an accredited college or university required. Bachelor’s degree from an accredited college or university preferred. Utilization review based certification 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 WORK ENVIRONMENT When applicable and appropriate, consideration will be given to reasonable accommodations. TAKING CARE OF YOU BY We offer a diverse and comprehensive benefits package including:Three Medical, and two dental plans to choose from. Tuition reimbursement eligible. 401K plan that matches 50% on every $ you put in up to the first 6% you save. 4 weeks PTO your first full year. NEXT STEPS If your application is selected to advance to the next round, a recruiter will be in touch. The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time. Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles. Apply To This Job