Job Description

As our Utilization Review Nurse, you will coordinate and perform all aspects of Worker's Compensation, auto, and general liability claims for medical management activity (IME/Peer Review, UR) to ensure optimum medical care service delivery, utilization of resources, and cost-effectiveness. The UR Nurse will also provide professional nursing expertise to the Medical Bill Review group as needed.

Core Responsibilities include:

• Perform all aspects of the Utilization Review Process
• Review records and requests for UR, which may arrive via mail, e-mail, fax, or phone
• Utilize evidence-based guidelines to determine if authorization can be given versus having to send the file for Peer or Physician Review
• Write nurse summaries on all UR files
• Document properly in Rising's database (and client databases when appropriate), and send determination letters on each completed UR
• Establish collaborative relationships with clients, patients, employers, providers, and attorneys
• Track the ongoing status of all UR activity so that appropriate turn-around times are met
• Maintain organized files containing clinical documentation of interactions with all parties of every claim
• Utilize good clinical judgment, careful listening, and critical thinking and assessment skills
• Respond to various written and telephonic inquiries regarding the status of the case
• Must be proficient in the use of a computer, including the use of various software programs simultaneously
• Print and mail all Massachusetts UR letters as assigned

Reports to:

Director of MRU

Requirements

• An Associate's or bachelor’s degree in Nursing
• Hold an active RN/LPN license in Illinois
• 3 to 5 years of clinical practice experience or 2 years of case management and/or UR experience
• More than one state license (a plus)
• You have your CCMC, CMAC, CRRN, CDMS or COHN (a plus)
• Experience with Workers' Compensation, short-term or long-term disability, or liability claims
• Bill review experience with Workers' Compensation, Auto and/or Health Insurance carriers
• The ability to set priorities and work both autonomously and as a team member
• Well-developed time-management, organization, and prioritization skills
• Excellent analytical skills
• Superb oral and written communication
• The ability to gather data, compile information and prepare summary reports
• Strong interpersonal and conflict-resolution skills
• Experience in a fast-paced, multi-faceted environment
• Demonstrated persistence and attention to detail
• General understanding of CPT and ICD-9/ICD-10 codes and Medicare guidelines
• Working knowledge of Microsoft Word, Excel, and Outlook
• Ability to remain calm during stressful situations
• A customer-service mindset

Working Conditions:

• Position is located in the Chicago Office
• Hours are 8:00 am to 4:00 pm Central Standard Time (9:00 am to 5:00 pm Eastern Standard Time)
• Remaining in a seated position
• Entering text or data into a computer
• Visual Acuity
• Talking
• Hearing
• Repetitive arm, hand, and finger motion

Benefits

• Health insurance (6 different plans to choose from)
• Dental
• Vision
• Paid time off (PTO) or Flexible Time Off (FTO)
• 401(k)
• Basic Life Insurance and Long-Term Disability Insurance (paid by the company)
• Voluntary Life Insurance and Short-Term Disability Insurance
• Flexible Spending Accounts (FSA)
• Employee Assistance Program (EAP)
• Rise Well Wellness Program
• Professional Development Reimbursement Program (PDRP)
• You will be part of our new Elevate program designed to recognize and reward employees for their hard work

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