Clinical Review Nurse

5 hours ago

King of Prussia, Pennsylvania, United States Elite Services Full time
Job Title: Utilization Review Nurse

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 the medical necessity of treatment 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, including injured workers, physicians, employers, therapists, attorneys, 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 the clinical director.
  • Complete production logging.
  • Assist the leadership team with training and coordinating back-up resources.
Requirements and 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.
Preferred Qualifications:
  • 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.

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