Utilization Review Nurse

Sedgwick • Boise, ID • 4h ago

By joining Sedgwick, you'll be part of something truly meaningful. It's what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there's no limit to what you can achieve.

Newsweek Recognizes Sedgwick as America's Greatest Workplaces National Top Companies

Certified as a Great Place to Work®

Fortune Best Workplaces in Financial Services & Insurance

Utilization Review Nurse

PRIMARY PURPOSE : To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes.

ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.

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.

Education & Licensing

Active unrestricted RN license in a state or territory of the United States required. Associate degree from an accredited college or university required. Bachelor's degree from an accredited college or university preferred. Utilization review based certification preferred.

Experience

Four (4) years of related experience or equivalent combination of education and experience required to include two (2) years of recent clinical practice or one (1) year of recent utilization review.

Skills & Knowledge

Strong clinical practice knowledge

Knowledge of the insurance industry and claims processing

Excellent oral and written communication, including presentation skills

PC literate, including Microsoft Office products

Analytical and interpretive skills

Strong organizational skills

Excellent interpersonal skills

Excellent negotiation skills

Ability to work in a team environment

Ability to meet or exceed Performance Competencies

TAKING CARE OF YOU BY

Offering a blended work environment.

Supporting meaningful work that promotes critical thinking and problem solving.

Providing on-going learning and professional growth opportunities.

Promoting a strong team environment and a culture of support.

Recognizing your successes and celebrating your achievements.

Thrives when everyone is working towards the same vision/goals.

We offer a diverse and comprehensive benefits package including:

Three Medical, and two dental plans to choose from.

Tuition reimbursement eligible.

401K plan that matches 50% on every $ you put in up to the first 6% you save.

4 weeks PTO your first full year.

NEXT STEPS

If your application is selected to advance to the next round, a recruiter will be in touch.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. 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 jurisdiction noted in this job posting only, the range of starting pay for this role is $73,000 - $75,000. 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.

Sedgwick is the world's leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company's expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see sedgwick.com

Similar Jobs

Registered Nurse

UnitedHealth Group • Meridian, ID • 4h ago

Hospital & Medical

Explore opportunities with Idaho Home Health, a part of LHC Group, a leading post-acute care partner for hospitals, physicians and families nationwide. As members of the Optum family of businesses, we are dedicated to he...

4h ago

Go to Apply

Medical Interpreter/Translator- Swahili

St. Luke's Health System • Boise, ID • 11h ago

Hospital & Medical

The Swahili Medical Interpreter/Translator facilitates clear, accurate and effective medical and general interpretation for healthcare staff, patients, companions, and visitors. Interpret complex medical information to p...

11h ago

Go to Apply

Account Manager (Pharmacy Benefit Management)

RxBenefits • Boise, ID • 16h ago

Hospital & Medical

The Account Manager position is one of the most crucial jobs within the organization. It directly supports the Broker(s) and Consultants during the after-sales phase of the business; then once the account is acquired, as...

16h ago

Go to Apply

Plant Operations Assistant - Surgical Center- Part-Time Phased to Full-Time - Treasure Valley Hospital

Surgery Care Affiliates • Boise, ID • 2d ago

Hospital & Medical

Overview At SCA Health, we believe health care is about people - the patients we serve, the physicians we support and the teammates who push us forward. Behind every successful facility, procedure or innovation is a team...

2d ago

Go to Apply

Clinical Social Worker - Fee For Service

Thriveworks • Caldwell, ID • 2d ago

Hospital & Medical Sponsored

Thriveworks is currently seeking Licensed Clinical Social Workers to provide a mix of telehealth and face-to-face sessions in Nampa, ID. At Thriveworks, we’re not just growing a practice—we’re building a movement to tran...

2d ago

Go to Apply

Clinical Social Worker - Fee For Service

Thriveworks • Caldwell, ID • 2d ago

Hospital & Medical Sponsored

Thriveworks is currently seeking Licensed Clinical Social Workers to provide a mix of telehealth and face-to-face sessions in Nampa, ID. At Thriveworks, we're not just growing a practice-we're building a movement to tran...

2d ago

Go to Apply

Clinical Social Worker - Fee For Service

Thriveworks • Middleton, ID • 2d ago

Hospital & Medical Sponsored

2d ago

Go to Apply

Global Clinical Operations Manager

GE Aerospace • Boise, ID • 2d ago

Hospital & Medical

Job Description Summary The Global Clinical Operations Manager provides international clinical leadership and operational oversight for occupational health services across multiple aerospace facilities. This role is acco...

2d ago

Go to Apply

Federal Clinical Measurement Support Nurse (DHA CQM Program)

St. George Tanaq Corporation • Boise, ID • 3d ago

Hospital & Medical

Federal Clinical Measurement Support Nurse (DHA CQM Program) Fully Remote-United States Job Type Full-time Description Overview Tanaq Management Services (TMS) delivers professional, scientific, and technical services an...

3d ago

Go to Apply

Licensed Talk Therapist - Fee For Service

Thriveworks • Meridian, ID • 3d ago

Hospital & Medical Sponsored

Thriveworks is currently seeking Licensed Clinicians to provide a mix of telehealth and face-to-face sessions in Nampa, ID. At Thriveworks, we’re not just growing a practice—we’re building a movement to transform mental...

3d ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.