Utilization Review Nurse (Remote)

Company Details Berkley Medical Management Solutions (BMMS) provides a different kind of managed-care service for W.R. Berkley Corporation. We believe focusing on an injured worker's successful and speedy return to work is good for people and good for Berkley's insurance operating units. BMMS was first started in 2014 by reimagining the relationship between medical need and technology to deliver the best outcome for injured workers and Berkley's operating units. Our goal was clear: combine solid clinical practices, proven return-to-work strategies and robust software into one system for seamless management of workers' compensation cases. To get it right, we started with a flexible technology platform that allowed for impressive customization without sacrificing the ability for expansion and continued innovation. We deploy integrated systems to give W.R. Berkley Companies recommendations and professional services for managing each individual case in an efficient and appropriate manner. The power of our technology takes medical bill-review services and clinical advisory services to a new level. Our unique marriage of technology, software platforms, data analytics and professional services ensures we provide Berkley's operating units with reliable results, and reduced time and expenses associated with case management.

Responsibilities

The Utilization Review Nurse for Workers' Compensation evaluates medical treatment requests to ensure they are appropriate, necessary, and compliant with applicable guidelines and regulations. This role supports high-quality care delivery while managing costs and ensuring timely decisions for injured workers.

• Review and assess medical treatment requests using evidence-based guidelines (e.g., ODG, ACOEM,MTUS).
• Make timely and accurate determinations regarding medical necessity.
• Collaborate with physicians, case managers, and claims adjusters to support appropriate care.
• Document and communicate decisions clearly and professionally.
• Escalate complex cases to physician reviewers when needed.
• Ensure compliance with state and federal regulations.
• Maintain confidentiality and adhere to HIPAA standards.
• Stay current with clinical guidelines and regulatory changes.
• Obtain Utilization Review certification within 2 years of hire date
• Earn Continuing Education Units to maintain certifications and licensures
• Obtain and maintain applicable state certifications and/or licensures in the state where job duties are performed
• Engage and participate in special projects assigned by case management leadership team
• Occasionally attend on site meetings and professional programs
• Foster a teamwork environment

Education

• Education: Registered Nurse (RN) license in good standing.
• Certifications Preferred: CCM, COHN, UR certification.

Qualifications

• 3+ years of clinical nursing experience
• 2+ years in utilization review or workers' compensation preferred.
• Strong knowledge of workers' compensation laws and medical guidelines.
• Excellent analytical, communication, and decision-making skills.
• Proficiency in EMR and UR platforms.
• Exhibit strong communication skills, professionalism, flexibility and adaptability
• Demonstrate evidence of self-motivation and the ability to perform UR duties independently
• Demonstrate evidence of computer and technology skills

Additional Company Details The Company is an equal employment opportunity employer. We do not accept unsolicited resumes from third party recruiting agencies or firms. The company offers a competitive compensation plan and robust benefits package for full time regular employees including:

• Base Salary Range: $80k-$90k
• Benefits include Health, dental, vision, dental, life, disability, wellness, paid time off, 401(k) and profit-sharing plans The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment.

Sponsorship Details Sponsorship not Offered for this Role Responsibilities The Utilization Review Nurse for Workers' Compensation evaluates medical treatment requests to ensure they are appropriate, necessary, and compliant with applicable guidelines and regulations. This role supports high-quality care delivery while managing costs and ensuring timely decisions for injured workers. - Review and assess medical treatment requests using evidence-based guidelines (e.g., ODG, ACOEM,MTUS). - Make timely and accurate determinations regarding medical necessity. - Collaborate with physicians, case managers, and claims adjusters to support appropriate care. - Document and communicate decisions clearly and professionally. - Escalate complex cases to physician reviewers when needed. - Ensure compliance with state and federal regulations. - Maintain confidentiality and adhere to HIPAA standards. - Stay current with clinical guidelines and regulatory changes. - Obtain Utilization Review certification within 2 years of hire date - Earn Continuing Education Units to maintain certifications and licensures - Obtain and maintain applicable state certifications and/or licensures in the state where job duties are performed - Engage and participate in special projects assigned by case management leadership team - Occasionally attend on site meetings and professional programs - Foster a teamwork environment Education - Education: Registered Nurse (RN) license in good standing. - Certifications Preferred: CCM, COHN, UR certification. Apply tot his job Apply To this Job