Utilization Review Nurse

Description Responsible for performing Workers’ Compensation utilization review, which includes prospective, concurrent, expedited, and retrospective reviews to determine medical necessity and appropriateness for requested medical care using evidence-based criteria. Through the discharge planning process, identify patients with ongoing case management needs and refer these claimants to the Case Management team for outreach and follow-up. Essential Duties and Responsibilities Conducts first-level prospective, concurrent, expedited, and retrospective utilization management, including inpatient services, outpatient services, surgeries, and ancillary service requests Reviews of all requests for treatment in accordance with specific state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria Evaluate treatment requests and review clinical information received with treatment protocols and guidelines, identify medical necessity, and refer to Peer Physician when appropriate. Reviews must be conducted within state jurisdiction and URAC timeframes. Review length of stay for inpatient cases when applicable Arrange alternative care services/discharge planning and refer to TCM as appropriate for coordinating of services Identify & review with Medical Director any case with potential safety issues Promote cost-effective health care with an aligned health provider network Identify and refer to Telephonic Case Management / Pharmacy TCM Coordinate with TCM / Pharmacy TCM to achieve appropriate next steps which align with TCM goals Manage determinations within the pharmacy portal Perform NY PAR in the onboard system in accordance with NY MTG Guidelines Additional Functions and Responsibilities Demonstrates ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards Maintain established template documentation standards adhering to URAC standards and company policies and procedures Maintain minimum billing and report billing hours in accordance with case activity and billing practices Maintain confidentiality - knowledge of laws and regulations pertaining to HIPPA and PHI Other job duties as assigned Qualifications Education: Diploma, Associate, bachelor’s degree in nursing, or Master’s level (or higher) degree in a Nursing, Health or Human Services field, or equivalent related experience preferred A current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required. Interstate nurse compact licensure is preferred. The candidate may be required to obtain additional licensure based on jurisdictional assignment. CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred Here are some of the benefits you can enjoy in this role: Medical, Dental, Vision Insurance. Life and Disability Insurance. 401(k) Plan Paid Holidays Paid Time Off. Referral bonus. Mental and Physical Requirements [see separate attachment for a copy of checklist of mental and physical requirements] MENTAL AND PHYSICAL REQUIREMENTS 1. MENTAL EFFORT Reasoning development: Follow one- or two-step instructions; routine, repetitive task. Carry out detailed but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. X Solve practical problems; variety of variables with limited standardization; interpret instructions. Logical or scientific thinking to solve problems; several abstract and concrete variables. Wide range of intellectual and practical problems; comprehend most obscure concepts. 2. PHYSICAL EFFORT Physical activity required to perform the job: Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. X Light work: a. Exerting up to 20 pounds of force occasionally b. Exerting up to 10 pounds frequently c. Exerting a negligible amount of force constantly to move objects (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work). Medium work: a. Exerting up to 50 pounds of force occasionally b. Exerting up to 20 pounds of force frequently c. Exerting up to 10 pounds of force constantly to move objects. Heavy work: a. Exerting up to 100 pounds of force occasionally b. Exerting up to 50 pounds of force frequently c. Exerting up to 20 pounds of force constantly to move objects. Very heavy work: a. Exerting in excess of 100 pounds of force occasionally b. Exerting in excess of 50 pounds of force constantly to move objects c. Exerting in excess of 20 pounds of force constantly to move objects. Visual requirements necessary to perform the job: Far vision: clarity of vision at 20 feet or more. X Near vision: clarity of vision at 20 inches or less. X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet. Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are. Color vision: ability to identify and distinguish colors. Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point. 3.

WORKING CONDITION

S Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure. WORKING CONDITION

ENVIRONMENTAL FACTOR

NATURE/REASON OF EXPOSURE

FREQUENCY

Dirt/Dust Noise Temperature extremes Dampness Vibrations Equipment movement hazard Chemicals/solvents Electrical shock Significant work pace/pressure Odors/Fumes Other (specify): Signatures: This job description has been approved by all levels of management: Human Resources: ___________________ The employee's signature below constitutes the employee's understanding of the mental and physical requirements, essential functions, and duties of the position. Employee____________________________ Date____________________ #J-18808-Ljbffr Tristar Risk Management