LVN - Utilization Review Nurse

AvonRisk; California; In loco; GBP 44.000 - 53.000; Tempo pieno

Vantaggi offerti da questo lavoro

Medical, dental, vision

HSA and FSA contributions

Life and disability insurance

401(k) with company match

PTO and holidays

Learning and development

Descrizione del lavoro

AvonRisk is seeking a utilization review nurse to assess medical records for the medical necessity of requests for services. The role emphasizes evidence-based guidelines and collaboration with Medical Director and Nurse Case Manager.

Work hours are Monday-Friday during standard business times. Candidates should have 3+ years clinical experience and familiarity with California Workers’ Compensation regulations; CA10 certification within one year is required.

Competenze

• Minimum of 3 years clinical experience.
• Familiarity with California Workers’ Compensation and managed care.
• Knowledge of MTUS, ACOEM, MCG, ODG guidelines (from context).
• IEA CA10 certification must be completed within 1 year.

Mansioni

• Review referrals for medical appropriateness using evidence-based guidelines.
• Identify diagnosis and treatment plan; validate diagnosis and care algorithms.
• Evaluate treatment protocols against local/regional/national guidelines.
• Coordinate with claims examiner, providers, and Physician Advisor as needed.
• Prepare questions for peer or third party review and assist in non-certification notifications.

Conoscenze

Clinical experience

Utilization Review

Multi-tasking

Organizational skills

Formazione

3+ years clinical experience

IEA CA10 certification

Descrizione del lavoro

Description

AvonRisk is the nation’s leading specialty risk manager for self-insured organizations, uniting respected regional leaders in workers’ compensation, liability, managed care, and risk management across 32 states. With nearly 700 professionals and brands including Intercare, InterMed, George Hills, and AS&G Claims Administration, we’re a people-focused, operations-driven organization that prioritizes reasonable caseloads, strong training, collaborative teams, and expert support. We invest in tools and workflows that reduce friction—not increase volume—and create real career paths for professionals who want to grow their careers or move into leadership. At AvonRisk, you’re part of a team that values good judgment, curiosity, and accountability, and gives you the support to succeed.

Description

AvonRisk is the nation’s leading specialty risk manager for self-insured organizations, uniting respected regional leaders in workers’ compensation, liability, managed care, and risk management across 32 states. With nearly 700 professionals and brands including Intercare, InterMed, George Hills, and AS&G Claims Administration, we’re a people-focused, operations-driven organization that prioritizes reasonable caseloads, strong training, collaborative teams, and expert support. We invest in tools and workflows that reduce friction—not increase volume—and create real career paths for professionals who want to grow their careers or move into leadership. At AvonRisk, you’re part of a team that values good judgment, curiosity, and accountability, and gives you the support to succeed.

Summary

The primary responsibility of the utilization review nurse is to review medical records to determine the medical necessity of a request for medical services. Previous work experience might include occupational medicine, orthopedics, and general medicine. An understanding of the workers’ compensation system is essential. Review and decisions are based upon evidence based guidelines including MTUS, ACOEM, ODG, MCG, and others. Using this information the UR Nurse is able to identify if requested medical services are within the guidelines for that specific injury and clinical history. The UR Nurse works closely with the Medical Director, and may also consult with an assigned Nurse Case Manager during the course of decision making. Additional training is provided. Work hours are Monday-Friday, usual business hours.

Essential Duties And Responsibilities

• Will receive and review referrals for treatment for medical appropriateness of treatment plan based on accepted evidence based guidelines and best practices.
• Will identify the medical diagnosis and treatment plan; validate diagnosis and corresponding algorithms of care.
• Will review treatment protocols and make recommendation using local, regional, and national recognized evidence base guidelines such as MTUS, ACOEM, MCG, ODG, state specific treatment guidelines, as well as documentation provided by the PTP.
• Will evaluate for over-utilization of treatment requests inconsistent with evidence based guidelines and when possible, negotiate with provider to amend or withdraw the treatment request when appropriate.
• Will refer potential non-certification cases to peer clinical reviewers.
• Arrange peer to peer contact with peer reviewer as needed and as requested by the requesting treating provider.
• Will direct and maximize the utilization of PPO/MPN networks.
• Pre-authorization of all appropriate inpatient and outpatient procedures.
• Will communicate with the claims examiner, providers, attorneys and any other auxiliary provider regarding UR determination in the prescribed given time frame set by each state, followed in written with in 24 hours.
• Will summarize medical records and all pertinent information presented with recommendation to Physician Advisor and/or prepare questions on complex cases for peer or third party review.
• Identify the need for medical case management and make recommendation for referral through supervisor.
• Will work closely with the client, claims handler, nurse case manager and supervisor, and take directions when needed.
• Responsible for conducting ongoing availability, monitoring oversight of non-clinical staff activities and task assigned.
• Assist in the notification process for the non-certification issued by the physician reviewer

Requirements

May be required to direct ancillary non-licensed personnel

Competency

To perform the job successfully, an individual should demonstrate the following competencies:

• Must be self-motivated with the ability to multi task and adapt to changing work priorities
• Must have strong organizational skills with attention to details
• Must have strong time management skills
• Must be able to work with a variety of clients and providers
• Must be able to follow directions

Qualification Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education And/or Experience

• Minimum of 3 years clinical experience
• California Worker’s Compensation, Managed Care experience/Utilization Review experience desired
• Needs to be familiar with California Worker’s Compensation regulations, medical terminology
• Completion is IEA CA10 is required within one year of employment

Salary Range

$59,000 - $71,000

The salary range listed is an estimate. Actual compensation will be determined based on several factors such as a candidate’s experience, qualifications, skill set, and work location.

Benefits

We take care of our people so they can take care of their work and their teams. AvonRisk offers a competitive, people first benefits package designed to support your health, financial security, and career growth, including:

• Comprehensive medical, dental, and vision benefits
• Company contributions to HSA and FSA plans
• Employer paid life and disability insurance
• 401(k) with company match
• Paid time off (PTO) and company paid holidays
• Learning and development opportunities that support real career advancement
• Employee assistance resources and a supportive culture that values balance and wellbeing

We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

Pursuant to the Los Angeles and San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest or conviction records.