Utilization Review Nurse

Job not on LinkedIn

🔥 12 hours ago

🇺🇸 United States – Remote

💵 $82k - $88k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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TRISTAR Insurance Group

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1987

💼 Consulting

🏥 Healthcare

📦 Logistics

Consulting • Healthcare • Logistics

TRISTAR Insurance Group is a national third-party administrator (TPA) that provides insurance administration and risk management services to employers, insurers and public entities. Its solutions include property & casualty, workers' compensation, general and auto liability, managed care (bill review, case management, utilization review, nurse triage, pharmacy benefit management), absence and disability management, employee group benefits administration, and risk control and workplace safety services. TRISTAR emphasizes collaborative, technology-enabled and tailored services to transform risk into opportunity for its clients.

📋 Description

• Perform Workers’ Compensation utilization review, including prospective, concurrent, expedited, and retrospective reviews • Determine medical necessity and appropriateness of requested medical care using evidence-based criteria • Review inpatient, outpatient, surgical, and ancillary service requests • Review treatment requests according to state guidelines, ODG, evidence-based guidelines, and client-specific authorization criteria • Evaluate clinical information and refer cases to a Peer Physician when appropriate • Review inpatient length of stay when applicable • Arrange alternative care services and discharge planning; refer claimants to Case Management/TCM • Identify and review potential safety issues with the Medical Director • Promote cost-effective healthcare through an aligned provider network • Coordinate with Telephonic Case Management and Pharmacy TCM • Manage determinations within the pharmacy portal • Perform NY PAR in the onboard system according to NY MTG Guidelines • Meet productivity, time-management, quality-assurance, billing, documentation, confidentiality, and company-policy requirements • Perform other assigned duties

🎯 Requirements

• Diploma, Associate, bachelor’s degree in nursing, or Master’s level (or higher) degree in a Nursing, Health or Human Services field, or equivalent related experience preferred • A current, unrestricted Registered Nurse (RN) or Licensed Practical Nurse (LPN) license recognized in the relevant jurisdiction(s) is required • Interstate nurse compact licensure is preferred • May be required to obtain additional licensure based on jurisdictional assignment • CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred • Conduct reviews within state jurisdiction and URAC timeframes • Maintain confidentiality and knowledge of laws and regulations pertaining to HIPPA and PHI • Light work and specified visual, physical, and repetitive-motion requirements

🏖️ Benefits

• Medical, Dental, Vision Insurance • Life and Disability Insurance • 401(k) Plan • Paid Holidays • Paid Time Off • Referral bonus