Onsite Utilization Review Nurse bei Rising Medical Solutions

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