This is a Remote position - Candidates must possess a Compact RN license

“Internal candidates outside of CA and MWRO will be considered”

Evaluates medical treatment requests to determine their necessity, appropriateness, and compliance with workers’ compensation laws and guidelines. The role involves collaboration with providers, claims examiners, nurse consultants, and internal teams to ensure injured employees receive medically necessary and timely care while managing costs effectively. The ideal candidate will have a strong clinical background, expertise in workers’ compensation regulations, and excellent decision-making skills.

The essential functions of this position include, but are not limited to, the following:

• Review medical treatment requests submitted for injured workers to ensure compliance with workers’ compensation guidelines, policies, and jurisdictional regulations.
• Assess the medical necessity and appropriateness of proposed treatments using evidenced-based criteria (e.g., Official Disability Guidelines (ODG), state-specific guidelines)
• Communicate approval or denial decisions to healthcare providers and claims adjusters in a clear and professional manner.
• Collaborate with medical directors for peer reviews or escalated cases requiring physician-level expertise.
• Document all reviews, decisions, and communications thoroughly and accurately in compliance with company policies and regulatory requirements.
• Identify potential red flags or patterns in treatment requests that may indicate overutilization or fraud.
• Proactively identifies injury severity, treatment plans, and clinical issues that require the attention of the Nurse Consultant or Sr. Nurse Consultant.
• Stay current with changes in workers’ compensation laws, treatment guidelines, and industry best practices.
• Utilize and manage resources appropriately, including UR/peer review, medical director, and vendors.
• Respond to various written and telephone inquiries timely regarding status of case.
• Consistently and accurately document interventions, rationale and recommendations in the Zenith system, utilizing the appropriate templates, and following Zenith guidelines, as indicated
• Educate claims staff, employers and other Zenith staff on medical issues, guidelines as needed and within corporate guidelines.
• Applies principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.
• Work productively and harmoniously with others on a consistent basis.
• Respond positively to direction and feedback on performance.
• Consistently maintain professional and appropriate demeanor.
• Perform other duties/projects as assigned.

Education, Skills and Experience Requirements

• Degree from an accredited nursing school required, with Bachelor of Science in nursing preferred.
• Maintain current unrestricted registered nurse (R.N.) license in the state where the position is based and other assigned states as required by law.
• Valid Driver’s License in good standing.
• Pursues continuing education as it pertains to maintaining RN licensure and certification, relating to workers’ compensation and utilization review practices.
• 1 year clinical experience required. Minimum 3 years preferred with practice with experience in orthopedics, neurology, or occupational medicine preferred. Preference for previous insurance, managed care or utilization experience.
• Secures professional certification such as CCM, CDMS, CRRN or COHN with two years
• Strong written and verbal communication skills in order to effectively communicate with injured employees, medical professionals, employers, claims staff and others.
• Good negotiation skills to successfully establish target return to work dates and manage medical and disability treatment plans.
• Proficient in basic computer skills, especially Microsoft Outlook and Office.
• Comfortable in a professional business environment.
• Bilingual in Spanish a plus.

The expected salary range for this position is $75,772.73 to $94,715.91. Actual pay will be adjusted based on experience, geographic location, and other job-related factors as permitted by law.

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Qualifications may warrant placement in a different job level.

Benefits

• Medical, Dental and Vision Insurance
• Flexible Spending Accounts
• Paid Parental Leave
• Life, AD&D and Disability Insurance
• 401(k), Employee Share Purchase Plan (ESPP)
• Education and Training Reimbursement
• Paid Leave: 3 weeks/year Vacation, 2 weeks/year Sick Leave
• 10 paid Company Holidays, 2 Personal Days, 2 Floating Holidays
• Employee Assistance Program (EAP)
• For more information, review details on the Benefits page of our Career Site: 

Zenith Insurance Company is an equal opportunity employer and considers all qualified applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristic. In compliance with California law, we are committed to fair hiring practices. Pursuant to the California Fair Chance Act (AB 1008), we will consider qualified applicants with criminal histories in a manner consistent with the law. Additionally, in accordance with the Los Angeles Fair Chance Initiative for Hiring Ordinance, we will not inquire about an applicant’s criminal history until after a conditional offer of employment has been made.

If you are a qualified individual with a disability or a disabled veteran and need assistance accessing our career center or applying for a position due to your disability, you are entitled to request an accommodation. To make a request, please contact a Human resources representative at Zenith Insurance Company.