RN Utilization Review

Company: Sedgwick
Location: Harrisburg
Posted on: June 23, 2022

Job Description:

**The 'Apply with SEEK' option will be utilized for International applicants, mainly Australia. If this does not apply to you please use the 'Apply' option.**

RN Utilization Review

IF YOU CARE, THERE'S A PLACE FOR YOU HERE

For a career path that is both challenging and rewarding, join Sedgwick's talented team of 27,000 colleagues around the globe. Sedgwick is a leading provider of technology-enabled risk, benefits and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. Whether they have a workplace injury, suffer property or financial loss or damage from a natural or manmade disaster, are involved in an auto or other type of accident, or need time away from work for the birth of a child or another medical situation, we are here to provide compassionate care and expert guidance. Our clients depend on our talented colleagues to take care of their most valuable assets-their employees, their customers and their property. At Sedgwick, caring counts -. Join our team of creative and caring people of all backgrounds, and help us make a difference in the lives of others.

**PRIMARY PURPOSE** : To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.

**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.

**ADDITIONAL FUNCTIONS and RESPONSIBILITIES**

+ Performs other duties as assigned.

+ Supports the organization's quality program(s)

**QUALIFICATIONS**

**Education & Licensing**

Active unrestricted RN license in a state or territory of the United States required. Bachelor's or Associate degree from an accredited college or university preferred. Utilization review based certification strongly preferred.

**Experience**

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.

**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**

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

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in (Colorado or New York City). Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the state noted in this job posting only, the range of starting pay for this role is $54,838 - $76,875. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

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 is an Equal Opportunity Employer and a Drug-Free Workplace.

Keywords: Sedgwick, Harrisburg , RN Utilization Review, Other , Harrisburg, Pennsylvania