RN Utilization Review

Sedgwick is the world’s leading risk and claims administration partner, helping clients thrive by navigating the unexpected. The company’s expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape.

PRIMARY PURPOSE: To utilize evidence based tools to evaluate the prescribed medications to ensure patient safety and quality standards are in alignment with best practice standards.

Performs clinical assessment via information in pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place. Evaluates patient drug usage and physician prescribing patterns. Evaluates overuse, underuse and misuse of prescribed medications and may recommend testing to determine if drug diversion is present. Evaluates need for and recommends alternative treatment. Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary. Negotiates appropriate level and intensity of care through use of medical and disability duration guidelines, adhering to quality assurance standards. Negotiates changes in pharmacy plan with providers. Acts as a resource in consulting with the client, nursing staff and claims examiners regarding pharmacy issues. Performs drug utilization reviews through the pharmacy benefit manager or vendor. Communicates effectively with claims examiner, client, vendor, supervisor and other parties as needed. Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards. ADDITIONAL FUNCTIONS and RESPONSIBILITIES Performs other duties as assigned. Supports the organization's quality program(s).