Description
By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve.
As a Utilization Review RN at Sedgwick, your primary purpose will be to provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.
Responsibilities:
- Identify treatment plan requests and obtain and analyze medical records that support the request.
- Clarify unclear treatment plan requests by contacting the requesting provider's office.
- Utilize evidence-based criteria and jurisdictional guidelines to form utilization review determinations.
- Pursue Physician Advisor services when treatment plan requests do not meet evidenced-based criteria.
- Negotiate treatment plan requests with requesting providers when medically appropriate and jurisdictionally allowed.
- Channel certified treatment plan requests to preferred vendors as necessary.
- Document all utilization review outcomes in utilization review software.
- Communicate and work with claim examiners as needed to provide clinical information to resolve issues.
- Maintain a score of 90% or higher on monthly internal utilization review audits.
- Meet productivity goals as outlined by your supervisor.
Additional Responsibilities:
- Perform other duties as assigned.
Qualifications:
- Current unrestricted RN license in a state or territory of the United States required.
- Associate degree from an accredited college or university required. Bachelor's degree from an accredited college or university preferred.
- Utilization review-based certification preferred.
- Four (4) years of related experience or equivalent combination of education and experience required, including two (2) years of recent clinical practice or one (1) year of recent utilization review.
Skills & Knowledge:
- Strong clinical practice knowledge.
- Knowledge of the insurance industry and claims processing.
- Excellent oral and written communication, including presentation skills.
- PC literate, including Microsoft Office products.
- Analytical and interpretive skills.
- Strong organizational skills.
- Excellent interpersonal skills.
- Excellent negotiation skills.
- Ability to work in a team environment.
- Ability to meet or exceed Performance Competencies.
Work Environment:
- Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem-solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines.
- Physical: Computer keyboarding, travel as required.
- Auditory/Visual: Hearing, vision, and talking.