Utilization Review Nurse

Sedgwick • San Juan, PR • 12h 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

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