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Onsite Utilization Review Nurse
Onsite Utilization Review NurseRising Medical Solutions • Chicago, IL, US
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Onsite Utilization Review Nurse

Onsite Utilization Review Nurse

Rising Medical Solutions • Chicago, IL, US
[job_card.30_days_ago]
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  • [job_card.full_time]
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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

  • An Associate's or bachelor’s degree in Nursing
  • Hold an active RN/LPN license in Illinois
  • 3 to 5 years of clinical practice experience or 2 years of case management and/or UR experience
  • More than one state license (a plus)
  • You have your CCMC, CMAC, CRRN, CDMS or COHN (a plus)
  • Experience with Workers' Compensation, short-term or long-term disability, or liability claims
  • Bill review experience with Workers' Compensation, Auto and/or Health Insurance carriers
  • The ability to set priorities and work both autonomously and as a team member
  • Well-developed time-management, organization, and prioritization skills
  • Excellent analytical skills
  • Superb oral and written communication
  • The ability to gather data, compile information and prepare summary reports
  • Strong interpersonal and conflict-resolution skills
  • Experience in a fast-paced, multi-faceted environment
  • Demonstrated persistence and attention to detail
  • General understanding of CPT and ICD-9/ICD-10 codes and Medicare guidelines
  • Working knowledge of Microsoft Word, Excel, and Outlook
  • Ability to remain calm during stressful situations
  • A customer-service mindset

Working Conditions:

  • Position is located in the Chicago Office
  • Hours are 8:00 am to 4:00 pm Central Standard Time (9:00 am to 5:00 pm Eastern Standard Time)
  • Remaining in a seated position
  • Entering text or data into a computer
  • Visual Acuity
  • Talking
  • Hearing
  • Repetitive arm, hand, and finger motion

Benefits

  • Health insurance (6 different plans to choose from)
  • Dental
  • Vision
  • Paid time off (PTO) or Flexible Time Off (FTO)
  • 401(k)
  • Basic Life Insurance and Long-Term Disability Insurance (paid by the company)
  • Voluntary Life Insurance and Short-Term Disability Insurance
  • Flexible Spending Accounts (FSA)
  • Employee Assistance Program (EAP)
  • Rise Well Wellness Program
  • Professional Development Reimbursement Program (PDRP)
  • You will be part of our new Elevate program designed to recognize and reward employees for their hard work
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Onsite Utilization Review Nurse • Chicago, IL, US

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