Utilization Review Nurse

Utilization Review Nurse

Spooner Medical Administrators, Incorporated (SMAI) is a family owned and operated company that offers rewarding career opportunities for motivated individuals who are passionate about excellence and growth. Since 1997, SMAI’s proactive philosophy and best practices have set the standard in workers’ compensation by continuously improving the delivery of case management, Utilization Review and billing services to help facilitate a successful return to work for the injured worker.

The Utilization Review Nurse is primarily responsible for reviewing treatment requests to ensure injured workers receive appropriate and timely medical care for their work-related injury.

Essential Functions

• Review treatment requests against established treatment guidelines to issue decisions regarding reimbursement for medical services.
• Work with the medical providers when insufficient information is available to make a determination regarding treatment reimbursement.
• Refer cases that do not meet guidelines to SMAI’s Medical Director or peer reviewer.
• Make determinations regarding the need for alternative treatment or services necessary to move the case towards a return to work.
• Assist Case Managers and Claim Analysts with understanding treatment reimbursement decisions.
• Review appeal requests and process accordingly; forward appeals to a peer review or IME as indicated; QA the review and produce a BWC order to reflect the reviewer’s decision; monitor the appeal through to completion.
• Use critical thinking skills and problem solving techniques throughout the Utilization Review process.
• Participate in continuous improvement activities and other assigned duties as assigned.

Supervision Received

Reports to the Utilization Review Supervisor

Experience and Education Required

• Current, unrestricted Ohio RN licensure
• Minimum of 1 year post-graduate experience in direct patient care
• General working knowledge of the medical Utilization Review process

Additional Skills Needed

• Effective written and verbal communication
• Detail oriented
• Strong organizational ability
• Basic computer literacy skills

Working Environment

The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions of the job. While performing the duties of this job, the employee typically works in a normal office environment. The noise level in the work environment is usually quiet.

Job Type: Full-time

Pay: $63,000.00 - $67,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Experience:

• Utilization Review: 1 year (Preferred)

License/Certification:

• Ohio RN (Preferred)

Work Location: In person