Job Title Utilization Reviewer

Summary: 

The Clinical Review Nurse position assesses the medical appropriateness of proposed treatments and medications for our injured employees, and partners with the Client Claims Adjuster team to expedite medically necessary treatment for each claim.  Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the Client organization.

Roles and Responsibilities: 

• PH Nurses to review treatment authorization request based on state guidelines and medical necessity and take decision to approve/deny. In case of denial send this to independent panel review to support the decision. Nurses will work with Claims adjuster on denial decision based on risk tolerance to ensure the denial doesn’t adversely affect the claim outcome.

• No licensing requirements. Occupational therapist or registered nurses with clinical background can perform this task.

• Perform Utilization Review activities prospectively, concurrently, or retrospectively in accordance with the appropriate jurisdictional and/or evidence-based guidelines.

• Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered.

• Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary

• Responsible for accurate comprehensive documentation of case management activities in case management system.

• Uses clinical/nursing skills to help coordinate the individual’s treatment program while maximizing quality and cost-effectiveness of care including direction of care to preferred provider networks where applicable.

• Addresses need for job description and appropriately discusses with employer, injured employee and/or provider. Works with employers on modifications to job duties based on medical limitations and the employee’s functional assessment.

• Responsible for helping to ensure injured employees receive appropriate level and intensity of care through use of medical and disability duration guidelines, directly related to the compensable injury and/or assist adjusters in managing medical treatment to drive resolution.

• Communicates effectively with claims adjuster, client, vendor, supervisor, and other parties as needed to coordinate appropriate medical care and return to work.

• Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications, and support systems in place.

• Objectively and critically assesses all information related to the current treatment plan to identify barriers, clarify, or determine realistic goals and objectives, and seek potential alternatives.

• Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome.

• Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim. 

• Engage specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director). 

• Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves.

• Keeps current with market trends and demands.

• Performs other functionally related duties as assigned.

Required Qualifications:

• Bachelor's degree in nursing (BSN) 

• Active unrestricted RN license that can be validated thru PRC website

• 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department

• Written and verbal fluency in English

• Candidate should be willing to work onsite (BGC)

• Candidate should be willing to work in US operation hours

Preferred: 

• Proficiency in all Microsoft Office products including Project, Word, Excel, PowerPoint, Visio, and SharePoint