About the role
Sedgwick is hiring a Utilization Review RN to work from home in Michigan. You'll review treatment plan requests against evidence-based criteria and jurisdictional guidelines, bring in physician advisors when requests don't meet criteria, and keep claim examiners informed. Quality is measured against a 90% monthly audit score.
Responsibilities
- Identify treatment plan requests and obtain and analyze the medical records that support them
- Contact provider offices to clarify unclear requests
- Use evidence-based criteria and jurisdictional guidelines to reach utilization review determinations
- Refer to physician advisors when a request doesn't meet evidence-based criteria
- Negotiate requests with providers when medically appropriate and allowed by the jurisdiction
- Send certified requests to preferred vendors as needed and document every outcome in UR software
- Work with claim examiners to resolve clinical questions and meet productivity goals
Requirements
- Current, unrestricted RN license in a U.S. state or territory
- Associate degree required; bachelor's preferred
- Four years of related experience, including 2 years of recent clinical practice or 1 year of recent utilization review
- Utilization review certification preferred
- Knowledge of the insurance industry and claims processing
- Maintain a 90% or higher score on monthly internal UR audits
- Strong clinical, communication, negotiation, and Microsoft Office skills
What we offer
- Work from home
- Employer with a recognized workplace culture (Great Place to Work certified)
- Career growth opportunities