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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, complete utilization review documentation, and support regulatory compliance and quality assurance.
Description
- Conduct high-quality utilization reviews using professional expertise and evidence-based guidelines
- Authorize care that meets medical necessity and appropriateness criteria
- Prepare peer review reports, correspondence, addendums, and supplemental reviews
- Collaborate with providers to determine the appropriate level, intensity, and duration of care
- Record findings and assess medical necessity based on service frequency, intensity, and length of care
- Complete reviews within applicable industry, client, federal, state, and URAC timeframes
- Stay current on URAC requirements and state and federal regulations
- Keep utilization review records accurate in the designated database
- Coordinate with Customer Service Representatives to support timely determination-letter delivery
- Help address client complaints and quality assurance matters
- Maintain compliance with ERISA, URAC, state guidelines, client agreements, and other regulatory standards
- Communicate compliance concerns and related insights to management
- Attend company meetings, training sessions, and continuing education activities
- Handle additional responsibilities as assigned
Requirements
- High school diploma or equivalent
- Graduation from an accredited nursing program
- An active, unrestricted Registered Nurse, Licensed Practical Nurse, or Licensed Vocational Nurse license
- Three to five years of direct professional patient-care experience
- Experience in utilization management 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 computers, fax machines, copiers, scanners, and telephones
- Familiarity with multiple software applications, including Microsoft Suite
- Ability to accurately follow instructions and management direction
- Consistent accuracy, thoroughness, quality ownership, and initiative to identify improvements
- Ability to work independently, prioritize responsibilities, and manage time effectively
- Ability to protect confidential information
- Ability to contribute to a positive, team-oriented work environment
- Ability to maintain focus and perform under pressure or stressful conditions
- Ability to respond appropriately to changes, delays, and unexpected events
- Ability to follow company policies and procedures
Benefits
- Medical, vision, and dental coverage
- Paid time off
- 401(k) plan
- Continuing education requirements
- Company meetings and training activities
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