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Career Field
Claims
Insurance
Discipline
All
Relocation
Assistance
Not Available
Job
Duration
Full Time
Salary
Offered
Open
In-house telephonic utilization review for prospective, concurrent, retrospective and appeal treatment requests for workers' compensation claims Responsible for adhering to the Massachusetts and California Utilization Review Criteria.
Job Components: Contact ordering provider upon notification of request for treatment to obtain pertinent medical findings. Information may be received telephonically, electronically or via mail. Assess medical case facts and apply critical thinking skills to determine medical necessity of requested treatment for prospective, concurrent and retrospective reviews, applying review criteria and treatment guidelines. UR determinations are supported with clinical rationale and concisely documented. Facilitate Peer Advisor review for second level determinations when indicated per established Best Practices Provide written and verbal notification of review determinations. Perform other duties as required.
Qualifications/Requisite Skills: RN/LPN licensure required (as per state requirements) Related clinical experience preferred (orthopedics, neurology, occupational health, Utilization Review) Strong computer skills Strong customer focus/communication and relationship management skills
