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Utilization Review Nurse

2 months ago

King of Prussia, United States Elite Services Full time
Utilization Review Nurse for Workers' Comp
Office Location - Upper Merion Township, PA

Job Purpose:
Review Workers Compensation requests submitted by the provider, requestor, claimant or carrier to determine the medical necessity of the treatment utilizing clinical expertise and evidence-based treatment guidelines.

**Please note that this is an In-office position.

Duties:
  • Perform an evaluation of the medical data for utilization review requests.
  • Confirm accurate completion of data intake.
  • Collect additional relevant data as needed with regard to determining medical necessity.
  • Analyze the collected data to apply evidence-based guidelines.
  • Review requests and make certification decisions, when appropriate, or prepare a case for peer review referral.
  • Coordinates information between all parties (injured worker, physicians, employer, therapists, attorney, etc)
  • Participate in audits of work product to ensure compliance.
  • Monitor daily processing inventory, including rush/urgent requests.
  • Provide inventory information and raise concerns to clinical director.
  • Complete production logging.
  • Assist leadership team with training and coordinating back-up resources.
Requirements/Skills/Qualifications:
  • Graduate of an accredited school
  • Valid current RN license in good standing
  • Able to perform the professional and technical skills of a Registered Nurse
  • Minimum 2 years of direct patient care
  • Excellent, written and oral communication skills
  • Ability to read and interpret medical reports and treatment guidelines
  • Must be able to maintain confidentiality
  • Must possess strong personal organizational skills
  • Must have experience and knowledge of intermediate computer skills
  • Ability to work independently with little to no supervision
  • Ability to work in a fast-paced and time-sensitive environment
  • Ability to meet deadlines in a production driven environment
  • Ability to work with WORD and EXCEL documents.
Preferences:
  • Experience in Utilization Review, Workers Compensation is a plus