Remote Utilization Review RN

Sedgwick; Detroit (MI); Remote; USD 80,000 - 100,000; Full time

Job summary

Sedgwick is seeking a Telecommuter RN for Utilization Review in Michigan. This full-time role focuses on evidence-based review of treatment plans, analyzing medical records, and coordinating with providers and claims teams.

The position emphasizes accuracy, adherence to guidelines, and cost-effective care outcomes. Ideal candidates hold an active RN license in the United States, with an associate degree (bachelor’s preferred) and utilization review certification.

Qualifications

• Current unrestricted RN license in the United States required
• Associate degree required; Bachelor’s degree preferred; Utilization review certification preferred

Responsibilities

• Identifies treatment plan requests and analyzes medical records to support the request
• Clarifies unclear treatment plan requests by contacting the provider’s office
• Uses evidence-based criteria and guidelines to form utilization review determinations
• Pursues Physician Advisor services when criteria are not met
• Negotiates treatment plans with providers when appropriate
• Routes certified treatment plans to preferred vendors as needed
• Documents utilizations review outcomes in software
• Communicates with claim examiners to resolve issues
• Maintains a 90%+ score on internal utilization review audits
• Meets productivity goals as directed by supervisor

Skills

RN license

Utilization review

Medical records analysis

Communication skills

Microsoft Office

Education

RN - Associate degree

Bachelor degree preferred

Tools

EHR systems

Microsoft Office

Job description

Sedgwick is seeking a Telecommuter RN for Utilization Review in Michigan. This full-time role focuses on evidence-based review of treatment plans, analyzing medical records, and coordinating with providers and claims teams.

The position emphasizes accuracy, adherence to guidelines, and cost-effective care outcomes. Ideal candidates hold an active RN license in the United States, with an associate degree (bachelor’s preferred) and utilization review certification.