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Clinical Review Nurse
2 months 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 for Workers' Compensation requests.
Job Purpose:The primary purpose of this role is to review Workers Compensation requests submitted by providers, requestors, claimants, or carriers to determine the medical necessity of treatment using clinical expertise and evidence-based treatment guidelines.
Duties and Responsibilities:- Perform an evaluation of the medical data for utilization review requests.
- Confirm accurate completion of data intake.
- Collect additional relevant data as needed to determine 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.
- 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 backup 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.
We are an equal opportunity employer and welcome applications from diverse candidates. If you are a motivated and detail-oriented Utilization Review Nurse looking for a new challenge, please submit your application.
