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ExamWorks operates at the intersection of healthcare, consulting, and legal services, providing independent medical examinations and peer reviews for claims and related processes. Its work also includes bill reviews, Medicare compliance, medical-record and document management, and compliance auditing.
The company supports a broad physician network and develops enterprise platforms and workflow tools for healthcare organizations. Its teams combine clinical, operational, compliance, and technology expertise to help clients manage medical records and claims with greater consistency and reliability.
Utilization Review Nurse Auditor — New Jersey Remote
ExamWorks is hiring a remote Utilization Review Nurse Auditor in New Jersey to assess medical necessity and authorize appropriate care. The role supports accurate, compliant utilization determinations, provider communication, and review documentation.
Description
- Conduct high-quality utilization reviews using evidence-based guidelines
- Authorize medically necessary and appropriate care
- Prepare peer review reports, correspondence, addenda, and supplemental reviews
- Collaborate directly with providers to determine the level, intensity, and duration of care
- Assess medical necessity based on care frequency, intensity, and required duration
- Complete reviews according to industry quality standards and required turnaround times
- Stay current on URAC and applicable state and federal regulatory requirements
- Maintain accurate utilization review records in the designated database
- Guide Customer Service Representatives in delivering determination letters on time
- Support the resolution of client complaints and quality assurance matters
- Ensure adherence to ERISA, URAC, and other applicable guidelines
- Provide management with observations about compliance concerns
- Attend company meetings, training sessions, and continuing education activities
- Complete other assigned responsibilities
Requirements
- High school diploma or equivalent is required
- Completion of an accredited nursing program
- An active, unrestricted Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse license is required
- Current coding certification in OASIS, RAC-CT, CCS, CPC, RHIT, or RHIA is required
- CPMA certification is preferred
- Three to five years of direct professional patient-care experience
- Utilization management experience is preferred
- Strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications, and laboratory values
- Typing proficiency of at least 40 words per minute
- Ability to use standard office equipment, including computers, fax machines, copiers, scanners, and telephones
- Working knowledge of Microsoft Suite and multiple software applications
- Ability to protect confidential information
- Ability to work independently, prioritize tasks, and manage time effectively
- Ability to perform under pressure while handling interruptions and unexpected situations
- Ability to follow company policies and procedures
Benefits
- Medical insurance coverage
- Vision insurance coverage
- Dental insurance coverage
- Paid time off
- 401(k) plan
- Continuing education requirements
- Company meetings and training activities
- Fully remote work arrangement
- Competitive benefits
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