Four (4) years of related experience or equivalent combination of education and experience required to include two (2) years of recent clinical practice or one (1) year of recent utilization review.
When applicable and appropriate, consideration will be given to reasonable accommodations.
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.
Auditory/Visual: Hearing, vision and talking
TAKING CARE OF YOU BY
Offering a blended work environment.
Supporting meaningful work that promotes critical thinking and problem solving.
Providing on-going learning and professional growth opportunities.
Promoting a strong team environment and a culture of support.
Recognizing your successes and celebrating your achievements.
We offer a diverse and comprehensive benefits package including: Three Medical, and two dental plans to choose from.
Tuition reimbursement eligible.
401K plan that matches 50% on every $ you put in up to the first 6% you save.
4 weeks PTO your first full year.
NEXT STEPS
If your application is selected to advance to the next round, a recruiter will be in touch.
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
Benefits
Health insuranceDental insuranceVision insurance401(k)Paid time offFlexible schedule
Additional Information
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.
Newsweek Recognizes Sedgwick as America's Greatest Workplaces National Top Companies
Certified as a Great Place to Work®
Fortune Best Workplaces in Financial Services & Insurance
RN Utilization Review
PRIMARY PURPOSE : To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.
ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.
ESSENTIAL FUNCTIONS and RESPONSIBILITIES
Identifies treatment plan request(s) and obtains and analyzes medical records that support the request.
Clarifies unclear treatment plan requests by contacting the requesting provider's office.
Utilizes evidence-based criteria and jurisdictional guidelines to form utilization review determinations.
Pursues Physician Advisor services when treatment plan requests do not meet evidenced-based criteria.
Negotiates treatment plan requests with requesting provider when medically appropriate and jurisdictionally allowed.
Channels certified treatment plan requests to preferred vendors as necessary
Documents all utilization review outcomes in utilization review software.
Communicates and works with claim examiners as needed to provide clinical information to resolve issues.
Maintains a score of 90% or higher on monthly internal utilization review audits.
Meets productivity goals as outlined by supervisor.
Education & Licensing
Active 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.
Sedgwick · Telecommuter