Utilization Review Registered Nurse
CLAIM YOUR FUTURE AS A GREAT PERFORMER!
Continuing double-digit revenue growth rates and progressive employment practices make Sedgwick Claims Management Services the place where great people can do great things for clients while maximizing their career possibilities. We have earned a reputation for innovation, quality, sustained growth, financial stability and a colleague-friendly work environment. We are proud to have been voted the Best TPA in America for 2005 and 2006, and the first and only Third Party Administrator to receive the coveted Employer of Choice designation. Come be a part of our team and 'Claim Your Future.'
PRIMARY PURPOSE: To provide services for dedicated units; to evaluate need for alternative services and as appropriate, assess, plan, implement, coordinate, monitor and evaluate options and services to meet an individual's health needs; to promote quality cost-effective outcomes through communication and available resources; and to provide quality, cost effective alternatives to acute care. ESSENTIAL FUNCTIONS and RESPONSIBILITIES - Delivers utilization review services; i.e., administrative continued stay review.
- Evaluates need for alternative treatment through telephonic contact and assessment with service provider.
- Negotiates price, level of care, intensity and duration with providers.
- Documents findings, implements alternative care, continues to evaluate medical necessity of frequency, intensity and length of care with physicians and agency/vendors.
- Maintains accurate record system of Utilization Review to include cost savings and data collection.
- Adheres to quality assurance standards.
- Interacts and coordinates work of Physician Advisors as necessary.
- May perform review of cases to identify referral for case management.
- Supports the total performance management initiative.
QUALIFICATIONS Education & Licensing
Baccalaureate degree from an accredited college or university preferred. RN licensure and CPUR or equivalent certification required. Experience
Three (3) years of recent clinical practice experience required. Skills & Knowledge - Strong utilization practice knowledge
- Knowledge of the insurance industry and claims processing
- Knowledge of current alternative resources and treatments in out-patient and alternative care settings
- 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
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, travel as required
Auditory/Visual: Hearing, vision and talking
The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time. Sedgwick CMS is an Equal Opportunity Employer and a Drug-Free Workplace
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