Utilization Review Nurse

Chicago, Illinois, United StatesFull-TimeMiddle

Salary not disclosed

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Job Details

Experience: 3 to 5 years of clinical practice experience or 2 years of case management and/or UR experience

Hold an Associate's or Bachelor's degree in Nursing.
Hold an active and unencumbered RN license in one or more states.
Have 3 to 5 years of clinical practice experience or 2 years of case management and/or utilization review experience.
Have experience with workers' compensation, short-term or long-term disability, or liability claims.
Understand CPT and ICD-9/ICD-10 codes and Medicare guidelines.
Have working knowledge of Microsoft Word, Excel, and Outlook.
Be proficient using a computer and multiple software programs simultaneously.
Demonstrate analytical, critical-thinking, assessment, and clinical-judgment skills.
Demonstrate time-management, organization, prioritization, persistence, and attention to detail.
Be able to work autonomously and as a team member, remain calm under stress, and handle conflict.
Be able to gather data, compile information, and prepare summary reports.
Work full time, 40 hours per week, Monday through Friday.

Perform all aspects of the utilization review process.
Review records and utilization review requests received by mail, email, fax, or phone.
Use evidence-based guidelines to determine whether authorization can be given or a file should be sent for peer or physician review.
Write nurse summaries for utilization review files.
Document activity in Rising's database and client databases when appropriate, and send determination letters for completed reviews.
Build collaborative relationships with clients, patients, employers, providers, and attorneys.
Track ongoing utilization review activity to meet appropriate turnaround times.
Maintain organized files with clinical documentation of interactions with all parties to each claim.
Respond to written and telephone inquiries about case status.

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