Utilization Review Nurse

Job not on LinkedIn

🔥 17 hours ago

🏄 California – Remote

🏄 California – Remote

💵 $59k - $71k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 1%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Intercare Holdings Insurance Services

WebsiteLinkedInAll Job Openings

201 - 500 employees

🛡️ Insurance

Insurance • Risk Management

Intercare Holdings Insurance Services is a privately held company that specializes in workers' compensation and liability claims administration, managed care services, and risk management solutions. Known for their client care and responsive service, Intercare integrates advanced technology and has an in-house Special Investigations Unit (SIU) to handle claims efficiently and reduce fraudulent activities. Their unique approach combines the depth and capacity of a large organization with the flexibility of a smaller firm, ensuring customized risk management and cost control solutions for clients. With a strong emphasis on customer satisfaction, Intercare is a trusted partner in reducing risk and maintaining fiscal stability for their clients.

📋 Description

• Review medical records to determine the medical necessity of requested medical services • Receive and review treatment referrals for medical appropriateness based on evidence-based guidelines and best practices • Identify medical diagnoses and treatment plans; validate diagnoses and corresponding care algorithms • Review treatment protocols and make recommendations using MTUS, ACOEM, MCG, ODG, state-specific treatment guidelines, and provider documentation • Evaluate over-utilization and negotiate with providers to amend or withdraw inappropriate treatment requests when possible • Refer potential non-certification cases to peer clinical reviewers and arrange peer-to-peer contact as needed • Direct and maximize utilization of PPO/MPN networks • Pre-authorize appropriate inpatient and outpatient procedures • Communicate utilization review determinations to claims examiners, providers, attorneys, and auxiliary providers within prescribed state time frames, followed in writing within 24 hours • Summarize medical records and pertinent information with recommendations to the Physician Advisor, or prepare questions for peer or third-party review • Identify the need for medical case management and recommend referrals through the supervisor • Work closely with clients, claims handlers, nurse case managers, and supervisors • Monitor availability and oversee non-clinical staff activities and assigned tasks • Assist with notification of physician-reviewer-issued non-certifications

🎯 Requirements

• Minimum of 3 years clinical experience • California Worker’s Compensation, Managed Care experience/Utilization Review experience desired • Familiarity with California Worker’s Compensation regulations • Familiarity with medical terminology • Completion of IEA CA10 is required within one year of employment • Understanding of the workers’ compensation system is essential • May be required to direct ancillary non-licensed personnel • Self-motivated with the ability to multitask and adapt to changing work priorities • Strong organizational skills with attention to detail • Strong time management skills • Ability to work with a variety of clients and providers • Ability to follow directions

🏖️ Benefits

• Comprehensive medical, dental, and vision benefits • Company contributions to HSA and FSA plans • Employer paid life and disability insurance • 401(k) with company match • Paid time off (PTO) and company paid holidays • Learning and development opportunities that support real career advancement • Employee assistance resources • Supportive culture that values balance and wellbeing • Additional training is provided

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