Utilization Review Registered Nurse (remote)

Santa Barbara Cottage Hospital; Pennsylvania; Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare provider is seeking a Utilization Review Registered Nurse to work remotely. The ideal candidate will have extensive experience in utilization review and prior authorization, ensuring compliance with medical treatment guidelines. Responsibilities include analyzing medical documentation and collaborating with the team to resolve claims efficiently. Strong analytical and communication skills are essential for this role.

Qualifications

• Minimum 3 years of UR/PA experience with a focus on workers' compensation.
• Experience interpreting medical treatment guidelines.

Responsibilities

• Perform PA reviews and make recommendations on workers’ compensation.
• Analyze medical documentation for compliance with treatment guidelines.
• Identify and resolve discrepancies or disputed claims.

Skills

Analytical

Communication

Problem-Solving

Tools

Electronic PA Processing Platforms

Job description

Utilization Review Registered Nurse (remote)

We are seeking experienced Registered Nurses with expertise in utilization review (UR), prior authorization (PA), medical documentation interpretation, and compliance with workers� compensation regulations and medical treatment guidelines (MTGs). The ideal candidate will have strong clinical experience in multiple domains, such as medications, procedures, imaging, mental health, etc., UR, and PA processes.

Responsibilities:

Perform PA reviews and make recommendations on workers� compensation, compliance, and completeness.

Analyze medical documentation to ensure appropriate utilization and compliance with medical treatment guidelines.

Identify and resolve discrepancies, denials, or disputed claims efficiently.

Work collaboratively with the team to ensure timely deliverables.

Maintain up-to-date knowledge of workers� compensation laws, treatment guidelines, and regulatory changes.

Qualifications:

Minimum 3 years of UR/PA experience with a focus on workers� compensation.

Experience interpreting medical treatment guidelines.

Knowledge of PA processes and regulatory compliance for workers' compensation cases.

Proficiency and understanding of electronic PA processing platforms.

Excellent analytical, communication, and problem-solving skills.

Ability to work independently and meet deadlines in a remote setting.

Preferred:

Experience with OnBoard Limited Release (OBLR) or similar prior authorization systems.

Familiarity with New York State Workers� Compensation Board regulations.