Utilization Review Nurse

Applied Underwriters is searching for a Utilization Management Nurse Reviewer to perform of day-to-day Utilization Management activities related to workers’ compensation, including, but not limited to, review of clinical information to determine medical necessity at all levels of care utilizing criteria- or evidence-based guidelines, interacting with physicians, claimants and peer reviewers as part of the Utilization Management process.  Applied Underwriters is setting the standard in the field of workers compensation.  Our expectation of a Utilization Management Nurse Reviewer is simple - continue to raise the bar.Essential Duties & Responsibilities

· Daily reviews submitted requests for certification of services or procedures involving claimants and validates medical necessity as per Promesa Health, Inc. policy and procedure guidelines. Under no circumstance will a nurse reviewer deny or modify such a request.

· Will be knowledgeable of URAC standards and comply with policies and procedures addressing URAC standards as established by Promesa Health, Inc.

· Will comply with federal, state or other regulatory agencies as well as internal policies and procedures related to such standards and requirements.

· Ensures cost effective and quality patient care by appropriate utilization of medical resources.

· Acts as a resource to the administrative staff and non-medical personnel, i.e. Contact Specialist and UM Intake Specialist.

· Assists the Manager of Utilization Management with ongoing development and implementation of the UM program and the Quality Management Program policies and procedures.

· Other duties as assigned by the Manager of Utilization Management.

 Qualifications & Requirements

· Requires a current and unrestricted RN license in the state of Nebraska or that of a compact state and at least 3 years of clinical experience; 5 years is preferred.

· Familiarity with utilization review process highly desired but not essential.

· Relies on extensive experience and judgment to plan and accomplish goals.

· Strong organizational skills and attention to detail strongly desired.

Paid medical and other health benefits, matching 401k, tuition reimbursement, fitness membership reimbursement, PTO plan and other benefits.