Utilization Review Nurse Case Manager
WFA Digital Insight
As the demand for skilled nurses in workers' compensation case management grows, AF Group's Utilization Review Nurse Case Manager role stands out for its blend of clinical expertise and analytical skills. With the workers' compensation market expected to reach $64 billion by 2027, professionals with experience in utilization review and case management are in high demand. This role requires a unique combination of medical knowledge, critical thinking, and communication skills, making it an exciting opportunity for nurses looking to transition into a new challenge. Before applying, candidates should be aware of the importance of staying updated on changing healthcare policies and workers' compensation rules.
Job Description
About the Role
The Utilization Review Nurse Case Manager plays a crucial role in ensuring that medical treatment for workers' compensation claimants is necessary, appropriate, and cost-effective. This role entails collaborating with physicians, peer reviewers, and claim handlers to determine the best course of treatment for each claimant. As part of a multidisciplinary team, the Utilization Review Nurse Case Manager will apply their clinical expertise and knowledge of jurisdictional rules to make informed decisions about medical necessity.The day-to-day responsibilities of this role will involve reviewing medical records, conducting prospective, concurrent, and retrospective medical necessity reviews, and communicating with healthcare providers to clarify treatment requests. The ideal candidate will have a strong background in nursing, excellent communication skills, and the ability to work collaboratively in a fast-paced environment.
What You Will Do
- Conduct comprehensive reviews of medical records to determine medical necessity and appropriateness of treatment
- Collaborate with physicians and healthcare providers to clarify treatment requests and determine the best course of treatment
- Communicate with claim handlers regarding treatment decisions, utilization trends, and determinations
- Apply standardized clinical guidelines to justify treatment approvals and document claim files accordingly
- Issue pre-authorizations for procedures, diagnostic tests, therapies, and equipment as needed
- Stay updated on changes in healthcare policies and workers' compensation rules to ensure compliance
- Prepare and submit clinical appeals when treatment requests are denied, supporting medical necessity with proper documentation
- Maintain timely and accurate documentation that complies with regulatory and URAC requirements
- Analyze utilization data to identify trends and areas for improvement
- Participate in quality assurance activities to ensure high-quality patient care
- Develop and maintain relationships with healthcare providers and other stakeholders to facilitate effective communication and collaboration
What We Are Looking For
- Registered nurse license active and unrestricted
- Bachelor's degree in nursing (BSN) preferred
- Compact and/or multiple state RN licenses, or the ability to obtain additional licenses
- Five years of active patient or clinical care experience as a Registered Nurse
- Three years of workers' compensation case management/utilization review, occupational health, rehabilitation, or insurance experience preferred
- Excellent oral and written communication skills
- Demonstrated leadership and project management abilities
- Ability and proficiency in the use of computers and Company standard software specific to position, including Microsoft Office products
- Strong clinical assessment, critical thinking, and communication skills
- Expertise in evidence-based guidelines
- Ability to analyze utilization data and identify trends
- Knowledge of clinical care and jurisdictional requirements
Nice to Have
- Experience with electronic medical records and healthcare software
- Certification in case management or utilization review
- Experience working in a remote or virtual team environment
Benefits and Perks
- Competitive salary range
- Comprehensive benefits package, including health, dental, and vision insurance
- 401(k) retirement plan with company match
- Paid time off and holidays
- Remote work stipend and equipment reimbursement
- Opportunities for professional development and continuing education
- Collaborative and dynamic work environment
How to Stand Out
- Be prepared to provide specific examples of your experience with utilization review and case management, highlighting your ability to apply clinical guidelines and make informed decisions about medical necessity.
- Showcase your excellent communication skills by providing examples of times when you effectively collaborated with healthcare providers and claim handlers to determine the best course of treatment.
- Familiarize yourself with the company's standard software and technology, and be prepared to discuss your experience with electronic medical records and healthcare software.
- Consider obtaining certification in case management or utilization review to demonstrate your expertise and commitment to the field.
- Research the company's approach to workers' compensation case management and be prepared to discuss your understanding of the industry and your role within it.
- Be prepared to negotiate your salary based on your experience and qualifications, and don't hesitate to ask about opportunities for professional development and continuing education.
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