Utilization review nurse [h1.location_city]

Job Description

Job Description

As our Utilization Review Nurse, you will coordinate and perform all aspects of Worker's Compensation, auto, and general liability claims for medical management activity (IME / Peer Review, UR) to ensure optimum medical care service delivery, utilization of resources, and cost-effectiveness. The UR Nurse will also provide professional nursing expertise to the Medical Bill Review group as needed.

Core Responsibilities include :

• Perform all aspects of the Utilization Review Process
• Review records and requests for UR, which may arrive via mail, e-mail, fax, or phone
• Utilize evidence-based guidelines to determine if authorization can be given versus having to send the file for Peer or Physician Review
• Write nurse summaries on all UR files
• Document properly in Rising's database (and client databases when appropriate), and send determination letters on each completed UR
• Establish collaborative relationships with clients, patients, employers, providers, and attorneys
• Track the ongoing status of all UR activity so that appropriate turn-around times are met
• Maintain organized files containing clinical documentation of interactions with all parties of every claim
• Utilize good clinical judgment, careful listening, and critical thinking and assessment skills
• Respond to various written and telephonic inquiries regarding the status of the case
• Must be proficient in the use of a computer, including the use of various software programs simultaneously
• Print and mail all Massachusetts UR letters as assigned

Reports to : Director of MRU

Requirements

Working Conditions :

Benefits