Role: UM Nurse Reviewer
Location: Tampa, FL-100% Remote
Duration: 12+ Months
Interview Mode: Webx
• Job holder will work with groups of Employees (EEs), and Functional Heads in addition to
individuals across a variety of tasks
• Performs Workers’ Compensation Utilization Management reviews in accordance with federal and
state-mandated regulations. Maintains compliance with regulatory changes affecting utilization management.
• Adheres to Department of Labor, state, and company WCUM timeframe requirements.
• Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results.
• Tracks status of all utilization management reviews in progress.
• Communicates with claims adjusters and/or providers on requests that need verification.
• Releases WCUM determinations to claim stakeholders following client-established protocols.
• Works closely with the management team in the ongoing development and implementation of utilization management programs.
• Certifies reviews that meet clinical review criteria/guidelines.
• Adheres to quality standards and state UM guidelines.
• Maintains all required utilization management review documentation in the UM software in a timely manner.
• Serves as the first-level contact for customer complaint resolution.
• Responds to inbound telephone calls pertaining to WCUM reviews in a timely manner, following client-established protocols.
• Processes customer calls consistent with program specified strategies and customer satisfaction measurements to include but not limited to the proper answering procedure, e.g. opening and closing remarks.
• Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
• Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
• Perform assigned tasks or work queues to assure cases are handled timely as well as meet established timelines for urgent requests.
• Adheres to Utilization Review Accreditation Commission (URAC), jurisdictional, and/or established best practice WCUM time frames, as appropriate.
• Manages assigned workload within established performance standards.
• Maintain confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.
• Adhere to program quality standards and maintain acceptable levels of performance, including
but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.
• Learn new methods and services as the job requires.
• Attend meetings to achieve departmental goals and objectives.
• Perform other duties as assigned or required.
• Must have a Bachelor’s Degree in Nursing with an active and unrestricted license to practice in at
At least one (1) year of clinical experience is preferred.
• Knowledge of nursing principles, techniques, and procedures for the care of patients.
• Knowledge of medical terminology, anatomy, physiology, and concepts of disease.
• Makes sound clinical decisions in a timely manner.
• Knowledge of basic ICD-9 or ICD 10 and CPT Coding is preferred.
• Knowledge on federal, state, URAC, and client protocols is preferred.
• Able to multi-task and prioritize assignments.
• Work on projects and meet deadlines.
• Skill in providing effective nursing care, assessing patient situations and taking effective courses of action.
• Detail oriented, with good organizational skills.
• Good critical and analytical thinking skills.
• Effectively meets strict deadlines.