Utilization Review Nurse

Please make sure to complete all the questions in the application and continue through to the end in order to sign and submit it.

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

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

a. 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.


b. Mathematical development:

Simple addition and subtraction; copying figures, counting, and recording.

Add, subtract, multiply, and divide whole numbers.

X Arithmetic calculations involving fractions, decimals, and percentages.

Arithmetic, algebraic, and geometric calculations.

Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.

Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.


c. Language development:

Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.

Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.

X Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.

Ability to compose original correspondence, follow technical manuals, and have increased contact with people.

Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.


2. PHYSICAL EFFORT

a. 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

1. 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

2. PHYSICAL EFFORT (cont.)


FREQUENCY


c. Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):

Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.

Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.

X Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.

X Kneeling: Bending legs at knee to come to a rest on knee or knees.

X Crouching: Bending the body downward and forward by bending legs and spine.

Crawling: Moving about on hands and knees or hands and feet.

X Reaching: Extending hand(s) and arm(s) in any direction.

X Standing: Particularly for sustained periods of time.

X Walking: Moving about on foot to accomplish tasks, particularly for long distances.

X Pushing: Using upper extremities to press against something with steady force in order to thrust forward, downward, or outward.

X Pulling: Using upper extremities to exert force in order to drag, haul, or tug objects in a sustained motion.

Foot


Motion: Using feet to push pedals.

X Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.

X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.

X Grasping: Applying pressure to an object with the fingers and palm.

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Frequently

Occasionally

2. PHYSICAL EFFORT (cont.)


FREQUENCY


X Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.

X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making fine adjustments on machined parts.

Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.

X Repetitive Substantial movements (motions) of the wrists, hands,


Motion: and/or fingers.


Frequently

Frequently

Frequently

3. WORKING CONDITIONS

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