Utilization Review RN: Evidence-Based Care Advocate

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

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