Registered Nurse – Workers' Comp Utilization Review Case Manager (Hybrid - Remote/In-Office)

County of Riverside; California; Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking dedicated Registered Nurses to join their Workers' Compensation Utilization Review team. This role offers the chance to work in a hybrid environment, balancing remote work with in-office collaboration. Candidates will assess medical services, provide recommendations, and ensure compliance with regulatory standards. With a focus on employee well-being, this position is ideal for those passionate about healthcare and committed to supporting injured workers. If you are a skilled RN with experience in utilization review and workers' compensation, this opportunity allows you to make a significant impact in a supportive environment.

Benefits

Remote Work Opportunity

Flexible Schedule

Professional Development

Health Benefits

Qualifications

• 5 years RN experience in Managed Care or Occupational Health with Workers' Compensation.
• Valid California RN license and Case Manager Certificate required.

Responsibilities

• Assess and evaluate medical services for injured employees.
• Perform utilization review and provide recommendations for treatment.

Skills

Utilization Review

Workers' Compensation

Managed Care

Occupational Health

Clinical Expertise

Problem Solving

Education

Bachelor's Degree in Nursing

Master's Degree in Nursing

Tools

California State Public Health Nursing Certificate

Case Manager Certificate

Job description

The County of Riverside’s Department of Human Resources is seeking both temporary and permanent Registered Nurses (RN) for the Workers' Compensation Utilization Review Nurse Case Manager position to support the County's Human Resources Workers' Compensation Division.

The most competitive candidates will have knowledge of CA MTUS, ACOEM, ODG and RFA's. Recent Registered Nurse experience with Utilization Review for a Workers' Compensation Department or self-insured program is highly preferred.

Additional Pertinent Information:

• 9/80 work schedule.
• This position offers the opportunity for remote work, with a hybrid schedule requiring 2 days in the office each week.
• In office during training from 8:00am - 5:30pm.

Responsibilities:

1. Assesses, plans, implements, coordinates, monitors and evaluates medical services, utilization review and return to work options for injured employees; is a department resource for medical inquiries, claim file reviews, and utilization review.
2. Provides medical, behavioral/motivational, occupational, and economic management activities for employees with work related injuries and provides early medical management intervention for new injuries, consulting on medical only and lost time injury files and utilization review on all requests for medical treatment.
3. Evaluates health care services of requesting physicians based on the appropriateness of the service and the level of care at which this service would be delivered; is a neutral advocate for employees.
4. Performs utilization review in concert with the utilization review physician to approve, delay, modify, or deny treatment.
5. Performs medical reviews on Workers' Compensation claims and provides recommendations which are preemptive, focused on moving the injured employee along the healing continuum, return to work opportunities, and employer protection.
6. Applies clinical expertise as a resource to the adjuster, employee, and the employer to identify the best results while coordinating the appropriate resource utilization; identifies and manages patient problems to eliminate duplication and fragmentation of health care services.
7. Assists in the development of policies and procedures, standards of care and practice, and in the monitoring of those standards to ensure regulatory compliance, as required by the Division of Workers' Compensation and the Department of Insurance.
8. Promotes collaboration among other departments, programs, physicians; represents the Workers Compensation Division when needed in business meetings.

Minimum Qualifications:

OPTION I

Experience: Five years full-time RN experience in a Managed Care or Occupational Health setting to include experience in Workers' Compensation and Utilization Review.

OPTION II

Education: A bachelor's Degree in Nursing, Health Related discipline or Education.

Experience: Three years of experience in Workers' Compensation and Utilization Review.

Possession of a valid California State Public Health Nursing Certificate.

OPTION III

Education: A Master's Degree in Nursing, Health Related discipline or Education.

Experience: Two years of experience in Workers' Compensation and Utilization Review.

Other Requirements (All)

License/Certificate:

Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California. Must possess and maintain a current Case Manager Certificate.

A valid California driver's license may be required.

Knowledge of:

Workers' compensation and utilization review principles and practices; managed care and occupational health issues and standards; application of the nursing process; full range of registered nurse duties and responsibilities; principles and methods of supervision and training; basic management skills; problem solving techniques.

Ability to:

Plan, organize, supervise and evaluate nursing services on specific unit(s); communicate effectively; positively manage change and conflict; interpret licensure and accreditation standards; analyze and draft department policies and procedures; apply productive problem solving skills; write clear and concise reports; perform registered nurse or public health nurse responsibilities according to the State of California Nurse Practice Act; implement the nursing process.

For further information regarding this posting, please contact Denise Decamp, ([e-mail]).