Utilization Review Nurse

Overview

The Utilization Review Nurse reports directly to the Manager, Medical Case Management. Performs utilization review activities for workers’ compensation claims.

Evaluates treatment requests, reviews available clinical information with treatment protocols, authorizes treatment, engages the Medical Director and/or forwards treatment requests to Peer Review for determination (where applicable) within established regulatory timeframes and company standards.  The Utilization Review Nurse does not issue non-certifications (denials).  This candidate must be able to channel authorized treatment within the Medical Provider Network and effectively negotiate treatment plans.

Responsibilities

• Conducts prospective, expedited, concurrent and retrospective reviews related to medical treatment requests for authorization.
• Ensure the privacy and security of Protected Health Information (PHI).
• Professional and effective communication with injured workers, medical professionals, claims staff, employers and all stake holders.
• Responds to various written and telephone inquiries in a timely manner regarding the status of the case.
• Engages in the proper use of resources including the TMC Medical Director, Peer Review, various vendors and other applicable resources to achieve optimal outcomes on each case.
• Forwards to the Medical Director or clinical peer reviewer’s cases which do not meet initial clinical criteria in the performance of utilization review. Utilization Review Nurses do not issue denials.
• Documents the use/ source of evidence based guidelines utilized during the clinical review requesting medical treatment authorization.
• Utilizes clinical and analytical skills to identify and refer cases for case management, as appropriate.
• Functions as a clinical resource to administrative assistants, claims staff, employers and injured workers.
• Reports any actual or potential quality issues or potential serious medical treatment concern issues to the Manager, Medical Case Management and/or Medical Director.
• Prioritizes and coordinates multiple responsibilities while working closely with internal and external customers.
• Maintains billable hours appropriate to role and assigned accounts.
• Must be able to work at least 40 hours per week, Monday thru Friday, and be available to work extended hours as situations arise.
• Negotiation skills are necessary to establish and facilitate treatment.
• Perform other related duties as required.

Qualifications

• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
• The requirements listed below are representative of the knowledge, skill, and/or ability required.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Graduate of accredited Registered Nursing Program. Current unrestricted California RN license.
• Bachelor of Science in Nursing (BSN) desirable.
• Strong clinical background in orthopedics, emergency room, intensive care, neurology, occupational medicine or rehabilitation useful.
• Strong cost containment background, such as utilization review or managed care also useful.
• One to two plus years of recent clinical experience and/or one to two years of recent managed care experience.
• Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents.  Ability to respond to common inquiries or complaints from customers, regulatory and governmental agencies, attorneys, or members of the business community.   
• Ability to write letters, memos and reports that conform to prescribed style, format and grammatical correctness.  Ability to effectively present information to top management, in claims and client settings. Strong written and verbal communication skills in order to effectively communicate with injured workers, medical professionals, employers, claims staff and others.
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages.
• Ability to define problems, collect data, establish facts, and draw valid conclusions. 
• Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables. Must have strong organizational, problem solving and time management skills.  Sound professional judgement

The salary range for this role is $40.00/hr. - $43.27/hr.. This range is only applicable for jobs to be performed in California. Base pay offered may vary depending on, but not limited to education, experience, skills, geographic location, travel requirements, sales or revenue-based metrics. This range may be modified in the future.

What We Offer

AmTrust Financial Services offers a competitive compensation package and excellent career advancement opportunities. Our benefits include: Medical & Dental Plans, Life Insurance, including eligible spouses & children, Health Care Flexible Spending, Dependent Care, 401k Savings Plans, Paid Time Off.

AmTrust strives to create a diverse and inclusive culture where thoughts and ideas of all employees are appreciated and respected. This concept encompasses but is not limited to human differences with regard to race, ethnicity, gender, sexual orientation, culture, religion or disabilities.

AmTrust values excellence and recognizes that by embracing the diverse backgrounds, skills, and perspectives of its workforce, it will sustain a competitive advantage and remain an employer of choice. Diversity is a business imperative, enabling us to attract, retain and develop the best talent available. We see diversity as more than just policies and practices. It is an integral part of who we are as a company, how we operate and how we see our future.

Salary : $40 - $43