Utilization Review Nurse

Job Title: Utilization Review Nurse, LPN, or RN

Position Type : Full time

Reports To: Manager Utilization Review & Specialty Products

Job Purpose: Ensuring all projects follow Case Management Standards of Practice

Promotes and restores individuals' health and wellbeing by completing “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes.”  ~CMSA Standards of Practice

Essential Functions

• Review treatment requests from medical professionals for adherence to state mandated guidelines

• Make determinations on which referrals can be authorized at the nurse level, and which will be sent for physician review

• Perform all necessary paperwork and billing from open to close of the UR review within state mandated and/or URAC turnaround time requirements

• At full-time status, the UR nurse will process a minimum of 12 reviews daily

• Document medical treatment requests and associated medical information in client records.

• Maintains client confidence and ethical and HIPAA standards by keeping information confidential.

• Maintains professional and industry knowledge by attending educational workshops; reviewing professional publications; establishing personal networks; participating in professional societies

• Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team problem-solving methods.

• Contributes to the Ascential Care Partners team effort by reflecting company philosophy and demonstrating ardent customer service-related results.

• Other duties as assigned from time to time.

Skills / Qualifications:

• Clear, active LPN license or RN License

• Ability to work any shift between 8:30AM and 8:30PM EST

• CA UR Nurse is required to work 11:30a-8p EST

• Strong organizational, task prioritization, and delegation skills

• Ability to maintain accurate records, prepare reports, correct English usage, and maintain confidentiality

• Computer literacy on Microsoft Office products and ability to learn new software

• Ability to construct grammatically correct reports using standard medical terminology

• Ability to use a computer keyboard and mouse 7-8 hours per day

• Dedicated work area allowing for maintaining confidentiality of records, access to high-speed internet and strong cellular phone service

Preferred:

• A minimum of 2 years’ experience in workers compensation utilization review

• Compact state license

Work Environment
This job operates in a professional or work-from-home office environment. This role routinely utilizes standard office equipment such as computers, phones, printers, filing cabinets and fax machines.

Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  While performing the duties of this job, the employee is regularly required to communicate with and listen to internal and external clients. The employee is required to sit frequently, frequently use the keyboard and mouse, occasionally stand; walk; and reach with hands and arms.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice. 

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Acrisure is committed to employing a diverse workforce. All applicants will be considered for employment without attention to race, color, religion, age, sex, sexual orientation, gender identity, national origin, veteran, or disability status.  California residents can learn more about our privacy practices for applicants by visiting the Acrisure California Applicant Privacy Policy available at www.Acrisure.com/privacy/caapplicant.
 

To Executive Search Firms & Staffing Agencies: Acrisure does not accept unsolicited resumes from any agencies that have not signed a mutual service agreement. All unsolicited resumes will be considered Acrisure’s property, and Acrisure will not be obligated to pay a referral fee. This includes resumes submitted directly to Hiring Managers without contacting Acrisure’s Human Resources Talent Department.