Utilization Review RN

Sedgwick Claims Management Services Ltd; Michigan; Hybrid; USD 75,000 - 95,000; Full time

Job summary

Sedgwick is seeking a registered nurse to provide timely, evidence-based utilization review services that maximize quality care and cost-effective outcomes for patients and clients. This role supports medical management by evaluating requests against established criteria and coordinating with providers.

You will identify treatment plan requests, obtain and analyze medical records, apply evidence-based criteria, and coordinate with providers and claim examiners to resolve issues while maintaining

Qualifications

• Current unrestricted RN license in a US state or territory.
• Associate degree required; Bachelor’s degree preferred.
• Utilization review based certification preferred.

Responsibilities

• Identifies treatment plan requests and analyzes medical records.
• Clarifies unclear requests by contacting providers.
• Uses criteria and guidelines to form utilization determinations.
• Negotiates treatment plans when appropriate and allowed.
• Documents outcomes in utilization review software.
• Collaborates with claim examiners to resolve issues.
• Maintains audit scores and productivity targets.

Skills

Clinical knowledge

Communication skills

Problem solving

Team orientation

Negotiation skills

Education

Associate degree

Bachelor’s degree preferred

RN licensure (US)

Utilization review certification preferred

Tools

Microsoft Office

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

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. Sedgwick is the world’s leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company’s expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see sedgwick.com.