Clinical Nurse Specialist
6 days ago
At Elite Services, we are seeking a skilled Utilization Review Nurse to join our team. As a Utilization Review Nurse, you will play a critical role in ensuring the medical necessity of treatment requests submitted by providers, requestors, claimants, or carriers.
Job Purpose:The primary purpose of this role is to review Workers' Compensation requests to determine medical necessity using clinical expertise and evidence-based treatment guidelines.
Duties and Responsibilities:- Perform an evaluation of medical data for utilization review requests.
- Confirm accurate completion of data intake.
- Collect additional relevant data as needed to determine medical necessity.
- Analyze collected data to apply evidence-based guidelines.
- Review requests and make certification decisions, when appropriate, or prepare a case for peer review referral.
- Coordinate 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.
- 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.
- Experience in Utilization Review, Workers Compensation is a plus.
Elite Services is an equal opportunity employer and welcomes applications from diverse candidates. We offer a competitive salary and benefits package. If you are a motivated and detail-oriented Utilization Review Nurse, please submit your application.
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