Utilization Review - RN
Location: Memphis Tennessee
Description: Sedgwick CMS is at the momment seeking for Utilization Review - RN right now, this occupation will be placed in Tennessee. More complete informations about this occupation opportunity please read the description below. Utilization Review RN
Providing both satisfying and challenging work along with a highly professional and friendly work atmosphere, Sedgwick Claims Management Services, Inc. ! has a strong commitment to its colleagues and its clients. If you are seeking place where you can do great things for those whose lives you touch while maximizing your own career possibilities, Sedgwick CMS is the place for you. As the largest and most innovative Third Party Administrator in the claims industry and the first and only TPA to receive both recognition as the Best TPA in America and the coveted Employer of Choice designation, we invite you to come be a part of our team and, 'Claim Your Future.'
PRIMARY PURPOSE: To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.
ESSENTIAL FUNCTIONS and RESPONSIBILITIES
Identifies treatment plan request(s) and obtains and analyzes medical records that support the request. Clarifies unclear treatment plan requests by contacting the requesting provider's office. Utilizes evidence-based criteria and jurisdictional guidelines to form utilization revie! w determinations. Pursues Physician Advisor services when trea! tment plan requests do not meet evidenced-based criteria. Negotiates treatment plan requests with requesting provider when medically appropriate and jurisdictionally allowed. Channels certified treatment plan requests to preferred vendors as necessary Documents all utilization review outcomes in utilization review software. Communicates and works with claim examiners as needed to provide clinical information to resolve issues. Maintains a score of 90% or higher on monthly internal utilization review audits. Meets productivity goals as outlined by supervisor. ADDITIONAL FUNCTIONS and RESPONSIBILITIES
Performs other duties as assigned. Supports the organization's quality program(s) QUALIFICATIONS
Education & Licensing
Baccalaureate or Associates degree from an accredited college or university preferred. Current unrestricted RN license required. Utilization review based certification strongly preferred.
Experience
Two (2) years of recent clinical ! practice or one (1) year of recent utilization review required.
Skills & Knowledge
Strong clinical practice knowledge Knowledge of the insurance industry and claims processing Excellent oral and written communication, including presentation skills PC literate, including Microsoft Office products Analytical and interpretive skills Strong organizational skills Excellent interpersonal skills Excellent negotiation skills Ability to work in a team environment Ability to meet or exceed Performance Competencies WORK ENVIRONMENT
When applicable and appropriate, consideration will be given to reasonable accommodations.
Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Physical: Computer keyboarding, travel as required
Auditory/Visual: He! aring, vision and talking
The statements contained in this document! are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.
Sedgwick CMS is an Equal Opportunity Employer
and a
Drug-Free Workplace
N/A
- .
If you were eligible to this occupation, please email us your resume, with salary requirements and a resume to Sedgwick CMS.
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This occupation starts available on: Sun, 16 Jun 2013 06:10:28 GMT