Utilization Review Nurse

Job Description

Worker's Compensation Utilization Review Nurse
(Remote, Florida)

Summary:
The Worker's Compensation Utilization Review Nurse evaluates the appropriateness and necessity of medical treatment through the Utilization Review process, while providing world-class service to injured workers in an accurate, efficient, and professional manner.

Responsibilities:

• Performs Worker's Compensation Utilization Review (prospective / concurrent / retrospective) for inpatient / put patient services reviews in accordance with federal and state mandated regulations.
• Maintains compliance with regulatory changes affecting utilization review.
• Processes Worker's Compensation Utilization Reviews for services against established clinical review guidelines and criteria.
• Adheres to Department of Labor, state, and company WCUR timeframe requirements.
• Monitors the status of assigned utilization management review through closure.
• Communicates with claims adjusters and / or providers on requests as needed.
• Processes WCUR determinations to claim stakeholders following client-established protocols.
• Adheres to quality standards and state Utilization Review (UR) guidelines.
• Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
• Manages, prioritizes, and processes assigned reviews within established performance & productivity standards.
• Communicates and escalates and potential problems as they become evident to leadership.
• Attends meetings as required.
• Performs other projects and duties as assigned.

Minimum Qualifications

• Current, active, and unrestricted Registered Nurse licensure in the state in which reviews are completed.
• Knowledge of basic ICD-9 or ICD-10, and CPT Coding is highly preferred.
• General knowledge of Worker's Compensation is preferred.
• Strong ability to multi-task, prioritize assignments and meet multiple deadlines.
• Detail oriented, with strong organizational, time management, critical / analytical thinking skills.
• Must have effective written and oral communication skills and be able to maintain confidentiality.
• Must be computer literate with the ability demonstrate PC knowledge through the use of Windows, MS Applications such as Microsoft Word, Excel, and Outlook.

Cognizant will only consider applicants for this position who are legally authorized to work in the United States without requiring company sponsorship now or at any time in the future.