Job Description
The Utilization Review Nurse is responsible for applying medical knowledge, judgment, jurisdictional rules, and medical treatment guidelines to review workers’ compensation medical necessity reviews. The Utilization Review (UR) Nurse engages with physicians, peer reviewers and collaborates with claim handlers to determine appropriate treatment decisions. The UR Nurse must be able to demonstrate and be accountable for the standards of practice, policies and procedures, quality assurance, and the goals of the organization. Also, review treatment of claimants through the workers’ compensation system based on the individual’s diagnosis, and jurisdictional regulations. Review medical records and treatment plans to determine medical necessity and appropriateness of medical treatment based upon established guidelines, and jurisdictional rules. Conduct prospective, concurrent, and retrospective medical necessity reviews. Apply standardized and appropriate clinical guidelines and document claim file to justify treatment approvals. Issue pre authorizations for procedures, diagnostic tests, therapies, and equipment. Collaborate with physicians and healthcare providers to clarify treatment requests. Communicate with claims handlers regarding treatment decisions, utilization trends, and determinations. Ensure UR processes comply with state workers' compensation guidelines and regulatory bodies. Maintain timely and accurate documentation that complies with regulatory and URAC requirements. Stay updated on changes in healthcare policies and workers’ compensation rules. Prepare and submit clinical appeals when treatment requests are denied, supporting medical necessity with proper documentation. EDUCATION Registered nurse license active and unrestricted required. Bachelor’s degree in nursing (BSN) preferred. Compact and or multiple state RN licenses, or the ability to obtain additional licenses. EXPERIENCE Five (5) years of active patient or clinical care experience as a Registered
