Utilization Review RN

Sedgwick; Michigan; On-site; USD 70,000 - 95,000; Full time

Job summary

Sedgwick is seeking a Utilization Review RN to provide timely, evidence-based utilization review services that maximize quality care and cost-efficiency. The role involves reviewing treatment plans, obtaining medical records, and applying criteria to determine authorizations, with collaboration across claim teams.

Qualified candidates hold an RN license with an associate degree and preferably a bachelor’s degree or UR certification.

Qualifications

• Current unrestricted RN license in the United States.
• Associate degree required; bachelor's preferred.
• Utilization review certification preferred.

Responsibilities

• Identify treatment plans and obtain medical records supporting requests.
• Clarify unclear requests by contacting the provider's office.
• Use evidence-based criteria to determine utilization review outcomes.
• Escalate to Physician Advisor when criteria are not met.
• Negotiate treatment plans with providers when appropriate.
• Route requests to vendors as needed.
• Document outcomes in UR software.
• Communicate with claim examiners to resolve issues.
• Maintain 90%+ monthly audit score.
• Meet productivity goals set by supervisor.

Skills

Clinical knowledge

Insurance & claims

Communication skills

MS Office

Analytical skills

Organizational skills

Interpersonal skills

Negotiation

Team collaboration

Performance management

Education

RN license

Associate degree

Bachelor's degree preferred

Utilization review certification preferred

Tools

Utilization review software

Job description

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies

Certified as a Great Place to Work®

Fortune Best Workplaces in Financial Services & Insurance

Utilization Review RN

PRIMARY PURPOSE

To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.

ESSENTIAL FUNCTIONS And RESPONSIBILITIES

• Identifies treatment plan request(s) and obtains and analyzes medical records that support the request.
• Clarifies unclear treatment plan requests by contacting the requesting provider's office.
• Utilizes evidence-based criteria and jurisdictional guidelines to form utilization review determinations.
• Pursues Physician Advisor services when treatment plan requests do not meet evidenced-based criteria.
• Negotiates treatment plan requests with requesting provider when medically appropriate and jurisdictionally allowed.
• Channels certified treatment plan requests to preferred vendors as necessary
• Documents all utilization review outcomes in utilization review software.
• Communicates and works with claim examiners as needed to provide clinical information to resolve issues.
• Maintains a score of 90% or higher on monthly internal utilization review audits.
• Meets productivity goals as outlined by supervisor.

ADDITIONAL FUNCTIONS And RESPONSIBILITIES

• Performs other duties as assigned.

Qualifications

Education & Licensing

Current unrestricted RN license in a state or territory of the United States required. Associate degree from an accredited college or university required. Bachelor’s degree from an accredited college or university preferred. Utilization review based certification preferred.

Experience

Four (4) years of related experience or equivalent combination of education and experience required to include two (2) years of recent clinical practice or one (1) year of recent utilization review.

Skills & Knowledge

• Strong clinical practice knowledge
• Knowledge of the insurance industry and claims processing
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Analytical and interpretive skills
• Strong organizational skills
• Excellent interpersonal skills
• Excellent negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.