CCMSI

Utilization Review Nurse

US-MA-Wakefield
Job ID
2017-2228
Category
Nursing

Overview

Cannon Cochran Management Services, Inc. (CCMSI) is a leading Third Party Administrator in self-insurance services headquartered in Danville, IL.  We are guided by core values including integrity, insisting on excellence and being passionately focused on customer service.  Those values, coupled with our Employee Stock Ownership Plan (ESOP), engage ownership with our employees and offers top of the line customer service for both our internal and external clients. 

 

This is a perfect opportunity to work in a growing, dynamic work environment.  CCMSI’s emphasis is on customer service and you will be expected to set and achieve performance goals in a challenging and growing team environment. 

 

The Utilization Review Nurse is responsible for comprehensive review of assigned Utilization Review requests from providers treating injured employees.

Responsibilities

  • Massachusetts Law requires workers' compensation insurers to undertake utilization review for all medical services to be provided to the injured employee from the date of injury.
  • Utilization Review concerns the quality of care provided to injured employees, including whether the service is appropriate and effective and the quality of treatment.  Appropriate service is health care service that is medically necessary and reasonable, and based on objective, clinical findings. 
  • Utilizes the Massachusetts DIA treatment guidelines, and proved references for guidelines and review criteria that the Department of Industrial Accidents (DIA) requires providers to consider when treating medical conditions. 
  • Reports the diagnosis, ICD 9 code, medical appropriateness of the service, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, follow‑up care and the injured employee's functional limitations. 
  • Authorize a determination based on the health care service request reviewed;  based on the information provided, meets or does not meet the clinical requirements for medical necessity and reasonableness of said service in accordance with appropriate medical guidelines.
  • The UR reviewer will process requests in accordance with the timelines specified in 452 CMR 6.00 for all determinations
  • Responds to all UR requests (voice mail and email) within 24 hours.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

Excellent verbal and written communication and interpersonal skills required. Attention to detail, planning and documentation. Discretion and confidentiality is a must. Possess a general knowledge of Workers compensation/Utilization Review process and Medical treatments.

 

Reliable, predictable attendance within client service hours for the performance of this position.

 

Responsive to internal and external client needs.

 

Ability to clearly communicate verbally and/or in writing both internally and externally.

 

Education and/or Experience                                                                    

 

2 years of clinical experience related to Trauma, Rehabilitation Therapy, Orthopedics, Workers’ Compensation or Public Health.

 

Computer Skills            

                                                               

Proficient with Microsoft Office programs. 

 

Certificates, Licenses, Registrations

 

Current unrestricted license RN, LPN, OT, PT.

 

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  

Object Handling Categories

Work requires the ability to lift/carry objects routinely as follows:

    

Light Lifting: No lifting of objects weighing more than 15 pounds on a regular basis.

 

CORE VALUES & PRINCIPLES

Responsible for upholding the CCMSI Core Values & Principles which include: performing with integrity; passionately focus on client service; embracing a client-centered vision; maintaining contagious enthusiasm for our clients; searching for the best ideas; looking upon change as an opportunity; insisting upon excellence; creating an atmosphere of excitement, informality and trust; focusing on the situation, issue, or behavior, not the person; maintaining the self-confidence and self-esteem of others; maintaining constructive relationships; taking the initiative to make things better; and leading by example.

 

 

CCMSI is an Affirmative Action / Equal Employment Opportunity employer offering an excellent benefit package including Medical, Dental, Prescription Drug, Vision, Flexible Spending, Life, ESOP and 401K.  

 

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If you are unable to locate a position that you are interested in that meets your qualifications, Connect with CCMSI for general consideration.