Utilization Review RN – Impactful Care & Cost Optimization

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

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.