The Utilization Review Specialist performs telephonic review of clinical services. This review will determine the medical necessity as well as alternative levels of care, utilizing clinical expertise, judgment and established criteria.
Associates Degree Or Equivalent
1 Or More Years Of Related Clinical Experience
1. Must be a registered nurse with a minimum of 1 year clinical experience in medical, surgical, orthopedic, neuro-surgery or psychiatric nursing.
2. Demonstrated knowledge of medical criteria.
3. Computer literacy.
1. Reviews and monitors the medical treatment plans of injured parties.
2. Applies clinical expertise, nursing judgment and established medical criteria to determine medical necessity of care proposed.
3. Review information in medical record; obtain and review informationfrom patient, physician and other participants in the care of patient; determine whether care of patient is an exception to established criteria for the diagnoses and problems that apply to that patient.
4. Review process and outcome of medical care by comparing actual careof individual patient with criteria of care established of the appropriate medical service.
5. May report on any adverse event or product complaint discovered through patient interaction.
6. Elevate to Medical Director cases not meeting criteria in a timely manner according to Best Practices.
Zurich Insurance Group (Zurich) is a leading multi-line insurance provider with a global network of subsidiaries and offices in Europe,...