Utilization Review Nurse

Tristar Risk Management; United States; Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Medical, Dental, Vision Insurance

Life and Disability Insurance

401(k) Plan

Paid Holidays

Paid Time Off

Referral bonus

Job summary

Tristar Risk Management is seeking an experienced nurse to perform Workers’ Compensation utilization review across prospective, concurrent, expedited, and retrospective cases. The role includes discharge planning and coordination with Case Management for ongoing patient needs.

Responsibilities cover reviewing treatment requests per guidelines, ensuring timely, compliant reviews, and collaborating with Medical Director on safety issues while promoting cost-effective care.

Qualifications

• Diploma/Associate/Bachelor’s degree in nursing or higher in Nursing/Health related field.
• Current, unrestricted RN or LPN license recognized in the relevant jurisdiction; interstate compact preferred.
• CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred.

Responsibilities

• Perform first-level utilization management including prospective, concurrent, expedited, and retrospective reviews for medical necessity.
• Review treatment requests per state guidelines, ODG, evidence-based guidelines, and client criteria.
• Refer to Peer Physician when appropriate and ensure reviews meet URAC timeframes.
• Coordinate discharge planning and refer to Case Management/TCM as needed.
• Identify safety concerns with Medical Director and promote cost-effective care within provider network.
• Utilize telephone case management/pharmacy TCM and manage pharmacy portal determinations.

Job description

Description

Responsible for performing Workers’ Compensation utilization review, which includes prospective, concurrent, expedited, and retrospective reviews to determine medical necessity and appropriateness for requested medical care using evidence-based criteria. Through the discharge planning process, identify patients with ongoing case management needs and refer these claimants to the Case Management team for outreach and follow-up.

Essential Duties and Responsibilities

• Conducts first-level prospective, concurrent, expedited, and retrospective utilization management, including inpatient services, outpatient services, surgeries, and ancillary service requests
• Reviews of all requests for treatment in accordance with specific state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria
• Evaluate treatment requests and review clinical information received with treatment protocols and guidelines, identify medical necessity, and refer to Peer Physician when appropriate. Reviews must be conducted within state jurisdiction and URAC timeframes.
• Review length of stay for inpatient cases when applicable
• Arrange alternative care services/discharge planning and refer to TCM as appropriate for coordinating of services
• Identify & review with Medical Director any case with potential safety issues
• Promote cost-effective health care with an aligned health provider network
• Identify and refer to Telephonic Case Management / Pharmacy TCM
• Coordinate with TCM / Pharmacy TCM to achieve appropriate next steps which align with TCM goals
• Manage determinations within the pharmacy portal
• Perform NY PAR in the onboard system in accordance with NY MTG Guidelines

Additional Functions and Responsibilities

• Demonstrates ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards
• Maintain established template documentation standards adhering to URAC standards and company policies and procedures
• Maintain minimum billing and report billing hours in accordance with case activity and billing practices
• Maintain confidentiality - knowledge of laws and regulations pertaining to HIPPA and PHI
• Other job duties as assigned

Qualifications

Education:

• Diploma, Associate, bachelor’s degree in nursing, or Master’s level (or higher) degree in a Nursing, Health or Human Services field, or equivalent related experience preferred
• A current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required. Interstate nurse compact licensure is preferred. The candidate may be required to obtain additional licensure based on jurisdictional assignment.
• CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred

Here are some of the benefits you can enjoy in this role:

• Medical, Dental, Vision Insurance.
• Life and Disability Insurance.
• 401(k) Plan
• Paid Holidays
• Paid Time Off.
• Referral bonus.

Mental and Physical Requirements

[see separate attachment for a copy of checklist of mental and physical requirements]

MENTAL AND PHYSICAL REQUIREMENTS

1. MENTAL EFFORT

Reasoning development: Follow one- or two-step instructions; routine, repetitive task.

Carry out detailed but uninvolved written or verbal instructions; deal with a few concrete variables.

Follow written, verbal, or diagrammatic instructions; several concrete variables.

X Solve practical problems; variety of variables with limited standardization; interpret instructions.

Logical or scientific thinking to solve problems; several abstract and concrete variables.

Wide range of intellectual and practical problems; comprehend most obscure concepts.

2. PHYSICAL EFFORT

Physical activity required to perform the job:

Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

X Light work: a. Exerting up to 20 pounds of force occasionally b. Exerting up to 10 pounds frequently c. Exerting a negligible amount of force constantly to move objects (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).

Medium work: a. Exerting up to 50 pounds of force occasionally b. Exerting up to 20 pounds of force frequently c. Exerting up to 10 pounds of force constantly to move objects.

Heavy work: a. Exerting up to 100 pounds of force occasionally b. Exerting up to 50 pounds of force frequently c. Exerting up to 20 pounds of force constantly to move objects.

Very heavy work: a. Exerting in excess of 100 pounds of force occasionally b. Exerting in excess of 50 pounds of force constantly to move objects c. Exerting in excess of 20 pounds of force constantly to move objects.

Visual requirements necessary to perform the job:

Far vision: clarity of vision at 20 feet or more.

X Near vision: clarity of vision at 20 inches or less.

X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet.

Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are.

Color vision: ability to identify and distinguish colors.

Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point.

3. WORKING CONDITIONS

Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure.

WORKING CONDITION

ENVIRONMENTAL FACTOR

NATURE/REASON OF EXPOSURE

FREQUENCY

Dirt/Dust

Noise

Temperature extremes

Dampness

Vibrations

Equipment movement hazard

Chemicals/solvents

Electrical shock

Significant work pace/pressure

Odors/Fumes

Other (specify):

Signatures:

This job description has been approved by all levels of management:

Human Resources: ___________________

The employee's signature below constitutes the employee's understanding of the mental and physical requirements, essential functions, and duties of the position.

Employee____________________________ Date____________________