LVN/LPN- Utilization Review Nurse

AvonRisk is a leading third-party administrator (TPA) and managed care solutions provider, backed by Aquiline Capital Partners. Formed through the combination of established TPA and managed care businesses, AvonRisk is building a platform designed to elevate what clients expect from claims and risk partners. We’re focused on creating a new kind of company—entrepreneurial at its core, collaborative in its model, and committed to bringing people, data, and technology together to deliver better outcomes across workers’ compensation, liability, and managed care. At AvonRisk, we see opportunity in change and strength in partnership. Our goal is to bring together like-minded teams across the country to build a modern, national platform that remains grounded in local expertise, service, and accountability.

The primary responsibility of the utilization review nurse is to review medical records to determine the medical necessity of a request for medical services. Previous work experience might include occupational medicine, orthopedics, and general medicine. An understanding of the workers’ compensation system is essential. Review and decisions are based upon evidence based guidelines including MTUS, ACOEM, ODG, MCG, and others. Using this information the UR Nurse is able to identify if requested medical services are within the guidelines for that specific injury and clinical history. The UR Nurse works closely with the Medical Director, and may also consult with an assigned Nurse Case Manager during the course of decision making. Additional training is provided. Work hours are Monday-Friday, usual business hours.

Will receive and review referrals for treatment for medical appropriateness of treatment plan based on accepted evidence based guidelines and best practices. Will identify the medical diagnosis and treatment plan; validate diagnosis and corresponding algorithms of care. Will review treatment protocols and make recommendation using local, regional, and national recognized evidence base guidelines such as MTUS, ACOEM, MCG, ODG, state specific treatment guidelines, as well as documentation provided by the PTP. Will evaluate for over-utilization of treatment requests inconsistent with evidence based guidelines and when possible, negotiate with provider to amend or withdraw the treatment request when appropriate. Will refer potential non-certification cases to peer clinical reviewers. Arrange peer to peer contact with peer reviewer as needed and as requested by the requesting treating provider. Will direct and maximize the utilization of PPO/MPN networks. Pre-authorization of all appropriate inpatient and outpatient procedures. Will communicate with the claims examiner, providers, attorneys and any other auxiliary provider regarding UR determination in the prescribed given time frame set by each state, followed in written with in 24 hours. Will summarize medical records and all pertinent information presented with recommendation to Physician Advisor and/or prepare questions on complex cases for peer or third party review Identify the need for medical case management and make recommendation for referral through supervisor Will work closely with the client, claims handler, nurse case manager and supervisor, and take directions when needed. Responsible for conducting ongoing availability, monitoring oversight of non-clinical staff activities and task assigned. Assist in the notification process for the non-certification issued by the physician reviewer