UR Nurse

MedRisk LLC; United States; On-site; USD 70,000 - 95,000; Full time

Job summary

Medata, a company of Medrisk, is hiring an UR Nurse to join the Utilization Review Program in the US. The Initial Clinical Reviewer evaluates medical treatment requests to determine medical necessity and compliance with workers’ compensation guidelines.

You will collaborate with providers, employers, therapists and attorneys to ensure timely and accurate determinations. Key duties include data collection, applying clinical guidelines, and performing various UR reviews.

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 ICD10, CPT codes and utilization review guidelines.
• Strong written and verbal communication skills.

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

Communication skills

Organizational skills

Independent work

Time management

Clinical knowledge

Tools

MS Word

MS Excel

Email

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

UR Nurse

Regular Full-Time US

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