Clinical Resource Reviewer
- Career Level
- Not Specified
York Risk Services Group is a premier provider of insurance, risk management, alternative risk, pool administration and claims management solutions to clients across hundreds of industries. Recently named by Forbes as one of "America's Best Midsized Companies 2017" We firmly believe that our employees drive the success of the company. With success in mind as the ultimate goal, we strive to create and provide an environment that offers challenging, stimulating and financially rewarding opportunities.
Regularly reviews appropriateness of treatment requests based on ODG and Miller criteria within timeframes outlined by the BWC. Functions as a clinical resource for the team to assist in their goal of facilitating the injured workers recovery and safe/timely return to work.
ESSENTIAL JOB RESPONSIBILITIES:
- Provide clinical guidance and support to managed care teams to ensure compliance with company and BWC policies and procedure
- Assess C-9 requests for medical services or additional conditions based on BWC and MCO guidelines.
- Assist with resolving return to work and clinical issues with the teams and the parties to the injury claim.
- Consult with the Medical Director for decision making as necessary.
- Audit medical treatment requests for appropriateness.
- Provide ongoing training to team members.
- Participate in, and assist with maintaining, case staffing and other quality management activities as appropriate.
- Uphold all URAC, BWC and FGMCS standards as defined in the organizations policies and procedures.
- Assist with the Drug Utilization Review (DUR) process.
- The Clinical Resource Reviewer reports to the Director of Clinical Services.
- The Clinical Resource Reviewer has no direct reports
- Licensure as a registered nurse in the state of Ohio.
- One of the following case manager certifications is preferred, but not required: Certified Rehabilitation Counselor (CRC), Certified Disability Management Specialist (CDMS), Certified Rehabilitation Registered Nurse (CRRN), Certified Occupational Health Nurse (COHN), or Certified Case Manager (CCM); or a Bachelors degree (or higher) in health or human services or related field.
- Two years full-time equivalent of direct clinical care to the consumer, preferably in: critical or emergent care; home health; occupational medicine; orthopedics; neurology; or sports medicine.
- Reviewing, understanding, and practicing within the scope of licensure.
- Maintenance of professional development, continuing education, and licensure.
- Excellent analytical, communication, computer, interpersonal, and problem solving skills.
- Excellent time management and organizational skills.
- Ability to work both individually and in a team environment.
- Knowledge and proficiency with Ohio Workers Compensation and managed care concepts.
- Knowledge of state and federal regulations (Ohio Workers Compensation, HIPAA, ADA, FMLA).