Remote Optum Utilization Review Jobs Near Me

The above represents the full salary range for this job requisition. Ultimately, in determining your pay and job title, we'll consider your location, education, experience, and other job-related factors, and will fall within the stated range. Your recruiter can share more information about the specific salary range during the hiring process.

Candidates who reside near our Charleston, WV office will work on average 1 day a week in the office. However, we are open to considering candidates who can work remote in any of our listed payroll approved states.

This role will report to a Director, Workers' Compensation Claims.

Are you a Referral?

If you know a current Encova Insurance associate and would like to apply as a referral, please encourage them to submit your referral information before you submit your application. You will receive an email with a direct URL link to the Job Posting of interest. Applying through this URL link will create your referral relationship for our Talent Acquisition Team.

Unique residence requirements are listed in each job posting, please review closely for details.

Encova is only able to employ associates who reside and work within specific U.S. states. Our current policies are based on the laws in states in which we are registered for payroll. Our current footprint includes:

Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, West Virginia, Wisconsin.

JOB OBJECTIVE:
The Nurse Case Manager serves as an office-based skilled medical resource for the business teams. The position's objective is to provide high quality customer service in workers' compensation medical case management and utilization review, primarily telephonically.The Nurse Case Manager provides medical expertise and serves a critical role in the cost containment of medical and indemnity expenses.

ESSENTIAL FUNCTIONS:
1. Complete early medical management assessment and intervention on workers' compensation claims requiring medical treatment. Contact injured workers and medical providers to obtain necessary information.
2. Apply knowledge, experience and evidence-based guidelines to evaluate claims and provide a proactive action plan.
3. Perform essential medical case management activities assessment, planning, implementation, monitoring and evaluation within accepted treatment guidelines.
4. Address medical cost containment through utilization management, collaboration with providers and assessing network resources.
5. Partner with appropriate team members to expedite injured worker recovery and return to work and to reduce disability costs.
6. Identify and monitor claims for task assignments to field case managers.
7. Evaluate accuracy of diagnoses of injuries or disabilities.
8. Document recommendations, contacts, actions and outcomes.
9. Adhere to jurisdictional regulations and standards.
10.Provide high quality customer service within a team-based environment.

OTHER FUNCTIONS:

1. Non-essential function: other duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES:

* Licensed Registered Nurse with no restrictions.
* Minimum of an Associate degree in nursing from an accredited college or university or successful completion of a diploma nursing program required. Bachelor's or Master's degree in nursing preferred.
* One year of experience in nurse case management, medical case management, utilization review, vocational/disability case management required.Workers' compensation experience is strongly preferred.
* Nationally recognized specialty certification in occupational or rehabilitative nursing or case management must be obtained as applicable, such as Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Certified Registered Rehabilitation Nurse (CRRN), or Certified Occupational Health Nurse (COHN). National certification may substitute for one year of experience requirement.
* Two years of clinical experience in orthopedics, neurology, rehabilitation, internal medicine, or occupational medicine is required.
* Multi-state case management experience is desired.
* Bilingual ability is a plus.
* Ability to collect relevant information, establish facts, and draw relevant conclusions, and recommend effective solutions.
* Working knowledge of evidence-based treatment guidelines, treatment protocols, medical causation and relatedness.
* Ability to efficiently coordinate effective medical treatment while maximizing cost containment.
* Ability to effectively collaborate with multiple team members and stakeholders.
* Strong planning and organizing skills.
* Working knowledge of the theory, principles, and practices of medical case management.
o Ability to maintain knowledge of current trends and developments in the medical case management field.
o Excellent oral and written communication skills.
o Demonstrate diplomacy, compassion and professional competency.
o Competent in Word, Outlook and Excel and capable of assimilating new systems applications and technology.
o Ability to work effectively in a paperless environment.

This position has been evaluated in accordance with the Americans with Disabilities Act. Encova Insurance makes every effort to reasonably accommodate disabilities to permit performance of the essential functions and candidates who need such accommodation are encouraged to seek it. This description reflects the nature and level of work performed by associates in this position. It is not an all-inclusive inventory of duties, responsibilities and qualifications required. It provides an accurate overview of the work and skills needed to perform this position. Because job content may change from time to time, Encova Insurance reserves the right to add and/or delete functions from this job as it deems necessary for business reasons.

Ready to join our team?
At Encova Insurance, we firmly believe that our associates drive our company's success by delivering unrivaled service to our customers. With success in mind, we make an ongoing effort to provide an environment that offers challenging, stimulating, and financially rewarding opportunities. Join us to discover a work experience where you can learn and grow to your fullest potential.

What you can expect from us

In addition to a competitive compensation package, we offer a comprehensive benefits package designed to support the well-being and growth of our associates. Available benefits (subject to any policy or plan changes) include, but are not limited to:

• Health, Dental & Vision Insurance

• Company-provided life and income protection plans

• Eligibility to participate in a company incentive bonus program

• 401(k) Retirement Plan - 100% company match up to 7% on annual salary

• Paid Time Off, Paid Holidays, and Floating Holidays

• Flexible Work Arrangements - Hybrid and remote depending on the role

We believe that happy, healthy associates are the foundation of great work. Join us and thrive both professionally and personally.

Encova Insurance is an EOE/E-Verify employer.