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By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

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RN Clinical Oversight

**PRIMARY PURPOSE** : To evaluate medical necessity and appropriate/efficient use of health care services, procedures and facilities under auspices of Bureau of Workers' Compensation (BWC) Managed Care Organization (MCO); to oversee case management processes as appropriate; and to ensure needs of injured workers are met through direct communication, education and available resources; and to promote quality outcomes.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

+ Evaluates the medical necessity, appropriateness and efficiency of the use of health care services, procedures and facilities through the receipt of requests for authorization of services; to render decisions on requests for authorization for services utilizing appropriate clinical pathways and evidence-based treatment guidelines (i.e. M&R, Chapter 7, Mercy, ODG); conducts case screening and evaluation of all medical documentation; develops and implements cost management strategies.

+ Maintains a working knowledge of the content of the MCO policy reference guide, BWC contract and CHS policy and procedures; revises compliance auditing as needed when updates are received; maintains knowledge of URAC case management standards and knowledge of medical management; maintains working knowledge of current medical care standards and practices; maintains professional development through membership in professional organizations and continuing education.

+ Works with Medical Director to identify clinical training needs and coordinates with trainer (s) to prepare/present to staff.

+ Utilizes peer reviewers and alternative dispute resolution (ADR) when appropriate; functions as clinical point of contact for BWC ADR unit as needed.

+ Reviews current plan of care with edits, past history and current status; communicates with injured workers and all related parties to the claim and documents contacts, interviews and information in appropriate system(s); staffs complex case management claims; provides direction for clinical decisions; oversees and coordinates treatment planning with relative parties to the claim; reviews plans for continuity of care and facilitates plan modifications.

+ Works with physician advisors and managers as appropriate to develop extended authorization workflow; maintains rapport with hospitals, physicians and health care provides.

+ Reviews and edits plan of care for continuity and promotes highest functional outcomes for the injured worker; re-evaluates acuity level.

+ Responds to internal and external customer inquiries within one (1) working day.

+ Consults with employer and provider services, BWC and employers as needed to determine needs and opportunities for improvement in the case management process.

+ Adheres to policies and procedures regarding documentation, confidentiality and appeals processes.

+ Evaluates medical claims as appropriate and provides profession opinion regarding medical necessity/acceptance or referral to Medical Director.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

+ Performs other duties as assigned.

+ Supports the organization's quality program(s).

+ Travels as required.

QUALIFICATIONS

Education & Licensing

Active unrestricted RN license required. Bachelor's degree from an accredited college or university preferred. Professional certification preferred (CDMS, CCM, CRRN, COHN).

Experience

Six (6) years of related experience or equivalent combination of education and experience required to include three (3) years in clinical practice specialty area. Three (3) years experience and proficiency with workers' compensation legal and regulatory requirements and quality/managed care concepts preferred.

Skills & Knowledge

+ Thorough knowledge of ADR problem solving and integration of case management and ADR concepts

+ Excellent oral and written communication, including presentation skills

+ PC literate, including Microsoft Office products

+ Strong problem solving skills

+ Strong analytical and interpretive skills

+ Strong organizational and time management skills

+ Excellent interpersonal skills

+ Detail oriented

+ Ability to work independently without close supervision

+ Ability to work in a team environment

+ Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT

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

**Mental:** Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

**Physical:** Computer keyboarding, travel as required

**Auditory/Visual:** Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.

Sedgwick is the world’s leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company’s expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see** **sedgwick.com