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Job Details

Utilization Review Case Manager RN (Remote) 2025-1434

Charleston, SC, USA

Medical Services

Full Time

Description

Utilization Review Case Manager RN, (Remote)

Overview

We believe in helping those with work-sustained illnesses and injuries to live their best life by providing care, health management, and support through our highly skilled team of home-based Utilization Review Case Managers.

Are you looking to make a difference by providing high-quality care with a personal touch that impacts the lives of members of the World Trade Center Health Program? Would you like to be part of a team focused on empowering and sustaining health by supporting members? Do you have the utilization review experience, and licenses necessary to help support members _?_

The Utilization Review Case Manager RN will provide timely, evidence-based utilization review services to ensure quality care and cost-effective outcomes. The role involves analyzing treatment plan requests, clarifying with providers, utilizing evidence-based criteria, consulting Physician Advisors, negotiating plans, and documenting outcomes. It also includes collaborating with departments, escalating cases, meeting productivity goals, maintaining privacy, participating in quality management, applying clinical standards, supporting the team, embracing change, working independently, and seeking growth opportunities.

Responsibilities

+ Identifies treatment plan request(s) and obtains and analyzes medical records that support the request.

+ Clarifies unclear treatment plan requests by contacting the requesting provider's office.

+ Utilizes evidence-based criteria and jurisdictional guidelines to form utilization review determinations.

+ Pursues Physician Advisor services when treatment plan requests do not meet evidence-based criteria.

+ Negotiates treatment plan requests with the requesting provider when medically appropriate and jurisdictionally allowed.

+ Channels certified treatment plan requests to preferred vendors as necessary.

+ Documents all utilization review outcomes in utilization review software.

+ Collaborates with case management, medical services, and the Medical Director as needed to optimize health outcomes.

+ Escalates cases that may require review for certification, diagnostic services, or case management to the appropriate department.

+ Meets productivity goals as outlined by supervisor.

+ Maintains privacy, as per Program guidelines, within a secure environment of documentation and communication.

+ Understand the organization's quality management program and the case manager's role within that program, with compliance with all SOPs within the Program’s Operations Manual.

+ Participates in department and organization quality management program including but not limited to department auditing procedures.

+ Experience with the application of industry and clinical standards of care as related to the needs of the Member population.

+ Is an effective team member; supports the team by pitching in at any level and effectively working across the organization to meet the needs of the business.

+ Takes ownership of personal actions and outcomes; encourages and empowers others to do the same.

+ Embraces change; maintains an open mind and is flexible and adaptable in the face of ambiguity and change.

+ Ability to work independently, multitask, and adjust priorities.

+ Proactively seeks opportunities to increase knowledge, skills, and abilities.

+ May perform other duties, as needed, to meet the needs of the business.

Qualification

+ Bachelor of Science in Nursing (BSN) or Associate in Nursing (ASN) or Nursing Diploma is required.

+ Utilization Review certification is strongly preferred

+ Unrestricted Current US State or Territory Registered Nurse License

+ Must hold a current nursing license of the state of residence

+ Over 4 years of clinical experience as a Registered Nurse, or an equivalent combination of education and experience

+ At least 2 years of recent clinical practice experience, or 1 year in utilization review.

+ Excellent written and verbal communication skills to collaborate with all stakeholders and team members.

+ Strong organizational skills

+ Excellent interpersonal skills

+ Ability to work in a team environment

+ Proficiency in computer use, including Microsoft Office Word, PowerPoint, Excel, and Outlook.

+ Must be a US citizen.

+ Ability to obtain and maintain security clearance.

+ Must pass credit, education, and background checks.

+ Willingness to travel as required.

For a career path that is both challenging and rewarding, join Sedgwick Government Solution’s talented team. Taking care of people is at the heart of everything we do. Our clients depend on our talented colleagues to take care of their most valuable assets, their employees, and their customers. At Sedgwick Government Solutions, caring counts®. Join our team of creative and caring people of all backgrounds and help us make a difference in the lives of others.

Sedgwick Government Solutions 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 a specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is ($70,000 - $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.

To be considered for this position, please submit a resume, and complete the application.

_The information provided above has been designed to indicate the general nature and level of work of the position. It is not a comprehensive inventory of all duties, responsibilities, and qualifications required._

Important Information

Successful candidates will be required to undergo a financial and criminal background check and obtain and maintain confidential-level security clearance upon hire. We participate in the United States Federal Government E-Verify program to confirm the employment authorization of the employee upon hire.

Search Firm Representatives

Please be advised that Sedgwick Government Solutions (Government Solutions) is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, a valid written agreement and task order must be in place before any resumes are submitted to Government Solutions. All resumes submitted by search firms to any employee at Government Solutions without a valid written agreement and task order in place will be deemed the sole property of Government Solutions and no fee will be paid in the event that person is hired by Government Solutions.

Government Solutions strives to make our career site accessible to all users. If you need disability-related accommodation to complete the application process, please contact Government Solutions regarding accommodations.

_Sedgwick Government Solutions is an Equal Opportunity and Affirmative Action Employer_

All qualified applicants will receive consideration for employment without regard to age, citizenship status, color, disability, marital status, national origin, race, religion, sex, sexual orientation, gender identity, veteran status, or any other classification protected by federal state or local laws as appropriate, or upon the protected status of the person’s relatives, friends or associates.

Sedgwick Government Solutions abides by the requirements of 41 CFR 60-741.5(a) (http://www1.eeoc.gov/employers/upload/eeoc\_self\_print\_poster.pdf) . This regulation prohibits discrimination against qualified individuals on the basis of disability and requires affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified individuals with disabilities.

Sedgwick Government Solutions abides by the requirements of 41 CFR 60-300.5(a) (http://www1.eeoc.gov/employers/upload/eeoc\_gina\_supplement.pdf) . This regulation prohibits discrimination against qualified protected veterans and requires affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified protected veterans.

About Sedgwick

Sedgwick Government Solutions is a fully owned subsidiary of Sedgwick. Sedgwick is a leading global provider of technology-enabled risk, benefits, and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. The company provides a broad range of resources tailored to clients' specific needs in casualty, property, marine, benefits, and other lines. At Sedgwick, caring counts®; through the dedication and expertise of more than 27,000 colleagues across 65 countries, the company takes care of people and organizations by mitigating and reducing risks and losses, promoting health and productivity, protecting brand reputations, and containing costs that can impact the bottom line. www.sedgwick.com Privacy | Sedgwick (https://www.sedgwick.com/privacy/) Terms and Conditions | Sedgwick (https://www.sedgwick.com/termsandconditions/)