Summary:
The primary responsibility of the utilization review nurse is to review medical records to determine the medical necessity of a request for medical services. Previous work experience might include occupational medicine, orthopedics, and general medicine. An understanding of the workers’ compensation system is essential. Review and decisions are based upon evidence based guidelines including MTUS, ACOEM, ODG, MCG, and others. Using this information the UR Nurse is able to identify if requested medical services are within the guidelines for that specific injury and clinical history. The UR Nurse works closely with the Medical Director, and may also consult with an assigned Nurse Case Manager during the course of decision making. Additional training is provided. Work hours are Monday-Friday, usual business hours.
Essential Duties and Responsibilities:
- Will receive and review referrals for treatment for medical appropriateness of treatment plan based on accepted evidence based guidelines and best practices.
- Will identify the medical diagnosis and treatment plan; validate diagnosis and corresponding algorithms of care.
- Will review treatment protocols and make recommendation using local, regional, and national recognized evidence base guidelines such as MTUS, ACOEM, MCG, ODG, state specific treatment guidelines, as well as documentation provided by the PTP.
- Will evaluate for over-utilization of treatment requests inconsistent with evidence based guidelines and when possible, negotiate with provider to amend or withdraw the treatment request when appropriate.
- Will refer potential non-certification cases to peer clinical reviewers.
- Arrange peer to peer contact with peer reviewer as needed and as requested by the requesting treating provider.
- Will direct and maximize the utilization of PPO/MPN networks.
- Pre-authorization of all appropriate inpatient and outpatient procedures.
- Will communicate with the claims examiner, providers, attorneys and any other auxiliary provider regarding UR determination in the prescribed given time frame set by each state, followed in written with in 24 hours.
- Will summarize medical records and all pertinent information presented with recommendation to Physician Advisor and/or prepare questions on complex cases for peer or third party review
- Identify the need for medical case management and make recommendation for referral through supervisor
- Will work closely with the client, claims handler, nurse case manager and supervisor, and take directions when needed.
- Responsible for conducting ongoing availability, monitoring oversight of non-clinical staff activities and task assigned.
- Assist in the notification process for the non-certification issued by the physician reviewer
May be required to direct ancillary non-licensed personnel
Competency:
To perform the job successfully, an individual should demonstrate the following competencies:
- Must be self-motivated with the ability to multi task and adapt to changing work priorities
- Must have strong organizational skills with attention to details
- Must have strong time management skills
- Must be able to work with a variety of clients and providers
- Must be able to follow directions
Qualification Requirements:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience:
- Minimum of 3 years clinical experience
- California Worker’s Compensation, Managed Care experience/Utilization Review experience desired
- Needs to be familiar with California Worker’s Compensation regulations, medical terminology
- Completion is IEA CA10 is required within one year of employment
United States
