Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. It’s an opportunity to do something meaningful, each and every day. It’s having support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive.
A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you’re someone who cares, there’s a place for you here. Join us and contribute to Sedgwick being a great place to work.
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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 review determinations.
- Pursues Physician Advisor services when treatment 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.
QUALIFICATIONSEducation & LicensingBachelor's or Associate degree from an accredited college or university preferred. Current unrestricted RN license in a state or territory of the United States required. Utilization review based certification strongly preferred.ExperienceFive (5) years of related experience or equivalent combination of education and experience required to include two (2) years of recent clinical practiceOR one (1) year of recent utilization review.Skills & Knowledge- Performs other duties as assigned.
- Supports the organization's quality program(s)
WORK ENVIRONMENTWhen 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 deadlinesPhysical: Computer keyboarding, travel as requiredAuditory/Visual: Hearing, vision and talkingThe 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.- Ability to meet or exceed Performance Competencies
- Ability to work in a team environment
- Excellent negotiation skills
- Excellent interpersonal skills
- Strong organizational skills
- Analytical and interpretive skills
- PC literate, including Microsoft Office products
- Excellent oral and written communication, including presentation skills
- Knowledge of the insurance industry and claims processing
- Strong clinical practice knowledge
- As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in (Colorado, CA, WA or New York City). Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the state noted in this job posting only, the range of starting pay for this role is $56,880 - $79,950. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.
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