Utilization Review Specialist

About the role

The serves as a critical intake and clinical resource within the workers' compensation ecosystem. This professional is responsible for the systematic triage and coordination of complex authorization and independent medical review requests. They leverage evidence-based medical guidelines to conduct in-depth reviews of authorization requests, ensuring clinical appropriateness and medical necessity. The role requires a proactive approach to researching claim files and interpreting detailed medical reports to guide decision-making. They act as a key advocate for the injured worker while simultaneously supporting the Claims department to align treatment plans with the specific diagnosis. This position requires balancing regulatory compliance with high-touch provider and member communication. The specialist must escalate nuanced cases to higher-level clinical leadership when authorization boundaries are exceeded. Ultimately, this role safeguards the integrity of the treatment authorization process through diligent analysis and clear documentation.

Key facts

What you'll do

• Triages and manages intake coordination of requests for authorization and independent medical review, ensuring timely processing.
• Reviews authorization requests for approval in accordance with evidence-based medical treatment guidelines to maintain clinical accuracy.
• Researches claim files; interprets medical reports; applies established guidelines to requested treatment to determine medical necessity.
• Advocates for the injured worker and Claims department to ensure treatment requests are appropriate for the diagnosis and regulatory standards.
• Escalates treatment requests outside of authorization authority for review by a Utilization Review Specialist 2 or Utilization Review Nurse for further evaluation.
• Ensures utilization review processes comply with time limits and requirements set by State law and Company policy to mitigate regulatory risk.
• Contacts providers to clarify treatment requests and examination findings; obtains additional medical information as needed to resolve ambiguities.
• Maintains understanding of Company policies regarding review of authorization requests by Utilization Review Specialists to ensure procedural fidelity.
• Maintains positive working relationship with Medical Bill Review staff for integrated medical management and seamless operations.
• Fosters positive working relationship with adjusting staff, Medical Management, Special Investigations Unit, Legal, Liens, Customer Care, and Client Services to support holistic case resolution.
• Maintains patient confidentiality and safeguards protected health information per State and Federal laws and Company policies to ensure compliance.
• Enters clear, concise, and accurate documentation of requested medical treatments, clinical findings, treatment guidelines, and determinations for audit trails.
• Ensures appropriate notices are forwarded to medical providers, injured workers, Claims staff, and attorneys to maintain transparent communication.
• You will Provides general office or administrative support throughout the department to facilitate team efficiency and effectiveness.

Requirements

• You need Bachelor's or Associate's degree in a medical field to ensure foundational clinical knowledge for the role.
• Minimum of 6 months of relevant experience and/or training in a medical field to demonstrate practical application of medical concepts.
• Ability to effectively use Microsoft Office/365 and become proficient in proprietary and vendor software applications to perform job functions.
• Ability to read and understand statutes, regulations, medical records, medical bills, medical resource materials, claim notes, and claim data fields to ensure accurate interpretation.
• Ability to write clear, concise reports conveying complex and nuanced information to stakeholders with varying levels of medical knowledge.
• Ability to present information and respond to questions with adjusting staff, Management, and others to facilitate collaborative decision-making.
• Ability to solve practical problems and deal with variables with limited standardization to handle unique case scenarios.
• Ability to interpret instructions in written, oral, diagram, graph, or schedule form to execute tasks precisely.
• Ability to apply arithmetic concepts (addition, subtraction, multiplication, division, fractions, percentages, ratios, proportions) to practical situations for data analysis.
• Attention to detail to double-check accuracy of information and work product to prevent errors and ensure compliance.
• Compliance with time limits and other requirements set by State law and Company policy to adhere to legal and operational standards.

Practical notes

Note: Triages and manages intake coordination of requests for authorization and independent medical review.

Reviews authorization requests for approval in accordance with evidence-based medical treatment guidelines.

Researches claim files; interprets medical reports; applies established guidelines to requested treatment.

Advocates for the injured worker and Claims department to ensure treatment requests are appropriate for the diagnosis.

Escalates treatment requests outside of authorization authority for review by a Utilization Review Specialist 2 or Utilization Review Nurse.

Ensures utilization review processes comply with time limits and requirements set by State law and Company policy.

Contacts providers to clarify treatment requests and examination findings; obtains additional medical information as needed.

Maintains understanding of Company policies regarding review of authorization requests by Utilization Review Specialists.

Maintains positive working relationship with Medical Bill Review staff for integrated medical management.