Job Type

Full-time, Temporary

Description

AvonRisk is the nation’s leading specialty risk manager for self-insured organizations, uniting respected regional leaders in workers’ compensation, liability, managed care, and risk management across 32 states. With nearly 700 professionals and brands including Intercare, InterMed, George Hills, and AS&G Claims Administration, we’re a people-focused, operations-driven organization that prioritizes reasonable caseloads, strong training, collaborative teams, and expert support. We invest in tools and workflows that reduce friction—not increase volume—and create real career paths for professionals who want to grow their careers or move into leadership. At AvonRisk, you’re part of a team that values good judgment, curiosity, and accountability, and gives you the support to succeed.

Summary

The primary responsibility of the utilization review nurse is to review medical records to determine the medical necessity of a request for medical services. Previous work experience might include occupational medicine, orthopedics, and general medicine. An understanding of the workers’ compensation system is essential. Review and decisions are based upon evidence-based guidelines including MTUS, ACOEM, ODG, MCG, and others. Using this information the UR Nurse is able to identify if requested medical services are within the guidelines for that specific injury and clinical history. The UR Nurse works closely with the Medical Director, and may also consult with an assigned Nurse Case Manager during the course of decision making. Additional training is provided. Work hours are Monday-Friday, usual business hours.

Essential Duties And Responsibilities

• Will receive and review referrals for treatment for medical appropriateness of treatment plan based on accepted evidence-based guidelines and best practices.
• Will identify the medical diagnosis and treatment plan; validate diagnosis and corresponding algorithms of care.
• Will review treatment protocols and make recommendation using local, regional, and national recognized evidence-based guidelines such as MTUS, ACOEM, MCG, ODG, state-specific treatment guidelines, as well as documentation provided by the PTP.
• Will evaluate for over-utilization of treatment requests inconsistent with evidence-based guidelines and when possible, negotiate with provider to amend or withdraw the treatment request when appropriate.
• Will refer potential non-certification cases to peer clinical reviewers.
• Arrange peer-to-peer contact with peer reviewer as needed and as requested by the requesting treating provider.
• Will direct and maximize the utilization of PPO/MPN networks.
• Pre-authorization of all appropriate inpatient and outpatient procedures.
• Will communicate with the claims examiner, providers, attorneys, and any other auxiliary provider regarding UR determination in the prescribed time frame set by each state, followed in writing within 24 hours.
• Will summarize medical records and all pertinent information presented with recommendation to Physician Advisor and/or prepare questions on complex cases for peer or third-party review.
• Identify the need for medical case management and make recommendation for referral through supervisor.
• Will work closely with the client, claims handler, nurse case manager, and supervisor, and take directions when needed.
• Responsible for conducting ongoing availability, monitoring oversight of non-clinical staff activities and task assigned.
• Assist in the notification process for the non-certification issued by the physician reviewer.