UR Nurse

MedRisk; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

Medata, a company of Medrisk, seeks an Initial Clinical Reviewer to join our Utilization Review Program. You will evaluate medical treatment requests for medical necessity, ensuring compliance with workers' compensation guidelines and collaborating with providers, employers, therapists and attorneys to ensure timely determinations.

The role requires clinical licensure, 2+ years direct patient care, and 1+ year of utilization review experience, with strong communication and data collection skills

Qualifications

• Active, unrestricted clinical license (RN, LVN, LPN).
• Minimum of two years of clinical experience providing direct patient care.
• Minimum of one year of utilization review experience, preferably workers' compensation.
• Knowledge of workers' compensation, utilization review processes and treatment guidelines.
• Knowledge of ICD10, CPT codes.
• Excellent written and verbal communication skills.
• Knowledge of medical/clinical guidelines (ODG, Interqual, Milliman, ACOEM or state-specific guidelines).
• High comfort level with computers and computer programs (MS Word, MS Excel, Email).
• Ability to maintain confidentiality.
• Strong organizational skills.
• Ability to work independently with minimal supervision.
• Ability to meet deadlines in a fast paced, time sensitive environment.

Responsibilities

• Review and evaluate requests for medical treatment and services under workers' compensation claims.
• Collect additional relevant data as needed with regard to determining medical necessity.
• Apply evidence-based clinical guidelines and state regulations to determine medical necessity.
• Perform Prospective, Concurrent, Retrospective and Appeal level reviews as assigned.
• Communicate with providers regarding clinical determinations and requests for additional information.
• Refer requests requiring physician review based upon utilization review protocols.
• Meet productivity, turnaround time and quality audit standards.
• Maintain knowledge of internal processing standards and workers' compensation regulations.

Skills

Clinical experience

Utilization review

Communication skills

Guidelines knowledge

ICD10/CPT knowledge

MS Word

MS Excel

Email

Confidentiality

Independence

Tools

MS Word

MS Excel

Email

Job description

Medata, a company of Medrisk is seeking Initial Clinical Reviewers to join our Utilization Review Program. The Initial Clinical Reviewer will be responsible for evaluating medical treatment requests to determine medical necessity, appropriateness and compliance with applicable workers' compensation guidelines and regulations. This role involves collaboration with healthcare providers, employers, therapist and attorneys to ensure timely and accurate utilization review determinations.

Duties:

• Review and evaluate requests for medical treatment and services under workers' compensation claims
• Collect additional relevant data as needed with regard to determining medical necessity
• Apply evidence-based clinical guidelines and state regulations to determine medical necessity
• Perform Prospective, Concurrent, Retrospective and Appeal level reviews as assigned
• Communicate with providers regarding clinical determinations and requests for additional information
• Refer requests requiring physician review based upon utilization review protocols
• Meet productivity, turnaround time and quality audit standards
• Maintain knowledge of internal processing standards and workers' compensation regulations

Requirements/ Skills/ Qualifications:

• Active, unrestricted clinical license (RN, LVN, LPN)
• Minimum of two years of clinical experience providing direct patient care
• Minimum of one year of utilization review experience, preferably workers' compensation
• Knowledge of workers' compensation, utilization review processes and treatment guidelines
• Excellent written and verbal communication skills
• Knowledge of medical/clinical guidelines (ODG, Interqual, Milliman, ACOEM or state -specific guidelines)
• Knowledge of ICD10, CPT codes
• High comfort level with computers and computer programs (MS Word, MS Excel, Email)
• Ability to maintain confidentiality
• Strong Organizational Skills
• Ability to work independently with minimal supervision
• Ability to meet deadlines in a fast paced, time sensitive environment