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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 seeking a remote Utilization Review Nurse Auditor in New Jersey to assess medical necessity, regulatory compliance, and care appropriateness. The role conducts evidence-based reviews and coordinates determination workflows.
Description
- Conduct quality utilization reviews and approve care that meets evidence-based medical necessity criteria
- Prepare peer review reports, correspondence, addenda, and supplemental reviews
- Collaborate with providers to assess the level, intensity, and duration of care
- Record findings and evaluate medical necessity across care frequency, intensity, and length
- Complete reviews within applicable industry, client, federal, state, and URAC turnaround standards
- Stay current with URAC and other relevant regulatory requirements
- Keep utilization review records accurate in the designated database
- Coordinate Customer Service Representatives to support prompt delivery of determination letters
- Support the resolution of client complaints and quality assurance matters
- Advise management about potential compliance concerns
- Attend company meetings, training sessions, and continuing education activities
- Handle other duties as assigned
Requirements
- High school diploma or equivalent
- Graduation from an accredited nursing program
- Active, unrestricted RN, LPN, or LVN license
- Current OASIS, RAC-CT, CCS, CPC, RHIT, or RHIA coding certification
- CPMA certification is preferred
- Three to five years of direct professional patient-care experience
- Prior utilization management experience is preferred
- Strong understanding of medical terminology, anatomy and physiology, treatment protocols, medications, and laboratory values
- Typing speed of at least 40 words per minute
- Ability to use computers, fax machines, copiers, scanners, and telephones
- Familiarity with multiple software applications, including Microsoft Suite
- Ability to protect confidential information
- Ability to work independently, prioritize tasks, and manage time effectively
- Ability to follow company policies and procedures
Benefits
- Medical, vision, and dental coverage
- Paid time off
- 401(k) plan
- Collaborative team environment
- Continuing education and training activities
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