Utilization Review Registered Nurse (remote)

Michigan Peer Review Organization; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare organization is seeking a Utilization Review Registered Nurse for a remote position. The ideal candidate will have at least 3 years of experience in utilization review and prior authorization, with strong analytical and communication skills. Responsibilities include reviewing medical documentation, ensuring compliance with treatment guidelines, and working collaboratively with a team. This role offers an opportunity to contribute to the efficiency of workers' compensation processes in a dynamic environment.

Qualifications

• Minimum 3 years of UR/PA experience focused on workers’ compensation.
• Experience interpreting medical treatment guidelines.
• Knowledge of PA processes and regulatory compliance.

Responsibilities

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

Skills

Analytical skills

Communication skills

Problem-solving skills

Tools

Electronic PA processing platforms

Job description

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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.