We are seeking experienced Registered Nurses with expertise in utilization review (UR), prior authorization (PA), medical documentation interpretation, and compliance with workers’ compensation regulations and medical treatment guidelines (MTGs). The ideal candidate will have strong clinical experience in multiple domains, such as medications, procedures, imaging, mental health, etc., UR, and PA processes.

QUALIFICATIONS:

Minimum 3 years of UR/PA experience with a focus on workers’ compensation.
Experience interpreting medical treatment guidelines.
Knowledge of PA processes and regulatory compliance for workers’ compensation cases.
Proficiency and understanding of electronic PA processing platforms.
Excellent analytical, communication, and problem-solving skills.
Ability to work independently and meet deadlines in a remote setting.

Perform PA reviews and make recommendations on workers’ compensation, compliance, and completeness.
Analyze medical documentation to ensure appropriate utilization and compliance with medical treatment guidelines.
Identify and resolve discrepancies, denials, or disputed claims efficiently.
Work collaboratively with the team to ensure timely deliverables.
Maintain up-to-date knowledge of workers’ compensation laws, treatment guidelines, and regulatory changes.