RN Utilization Review

Primary Purpose

To utilize evidence based tools to evaluate the prescribed medications to ensure patient safety and quality standards are in alignment with best practice standards.

We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.

• Performs clinical assessment via information in pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place.
• Evaluates patient drug usage and physician prescribing patterns.
• Evaluates overuse, underuse and misuse of prescribed medications and may recommend testing to determine if drug diversion is present.
• Evaluates need for and recommends alternative treatment.
• Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary.
• Negotiates appropriate level and intensity of care through use of medical and disability duration guidelines, adhering to quality assurance standards.
• Negotiates changes in pharmacy plan with providers.
• Acts as a resource in consulting with the client, nursing staff and claims examiners regarding pharmacy issues.
• Performs drug utilization reviews through the pharmacy benefit manager or vendor.
• Communicates effectively with claims examiner, client, vendor, supervisor and other parties as needed.
• Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards.

• Performs other duties as assigned.
• Supports the organization's quality program(s).

Active unrestricted RN license in a state or territory of the United States required. Bachelor's degree in nursing (BSN) from an accredited college or university or equivalent work experience preferred. Certification in case management, pharmacy, rehabilitation nursing or a related specialty is highly preferred.

Four (4) years of related experience or equivalent combination of education and experience required to include two (2) years of direct clinical care OR two (2) years of case management/utilization management.

• Knowledge of pharmaceuticals used to treat pain
• Knowledge of behavioral health
• Knowledge of pain management process
• Knowledge of drug rehabilitation process
• Knowledge of workers' compensation laws and regulations
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Leadership/management/motivational skills
• Analytic 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

When applicable and appropriate, consideration will be given to reasonable accommodations.

• 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.

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.

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to…