Clinical Utilization Review Specialist

1 week ago


Phoenixville, Pennsylvania, United States Elite Full time
Job Summary

We are seeking a skilled Clinical Utilization Review Specialist to join our team at Elite. The successful candidate will be responsible for reviewing Workers Compensation requests to determine medical necessity of treatment.

Key Responsibilities:

  • Utilization Review experience is required.
  • Perform an evaluation of medical data for utilization review requests.
  • Confirm accurate completion of data intake.
  • Collect additional relevant data as needed to determine medical necessity.
  • Analyze collected data to apply evidence-based guidelines.
  • Review requests and make certification decisions, when appropriate, or prepare a case for peer review referral.
  • Coordinate information between all parties (injured worker, physicians, employer, therapists, attorney, etc).
  • Participate in audits of work product to ensure compliance.
  • Monitor daily processing inventory, including rush/urgent requests.
  • Provide inventory information and raise concerns to clinical director.
  • Complete production logging.
  • Assist leadership team with training and coordinating back-up resources.

Requirements:

  • Graduate of an accredited school.
  • Valid current LVN, LPN, or RN license in good standing.
  • Able to perform the professional and technical skills of a Registered Nurse.
  • Minimum 2 years of direct patient care.
  • Excellent, written and oral communication skills.
  • Ability to read and interpret medical reports and treatment guidelines.
  • Must be able to maintain confidentiality.
  • Must possess strong personal organizational skills.
  • Must have experience and knowledge of intermediate computer skills.
  • Ability to work independently with little to no supervision.
  • Ability to work in a fast-paced and time-sensitive environment.
  • Ability to meet deadlines in a production driven environment.
  • Ability to work with WORD and EXCEL documents.

Preferred Qualifications:

  • Experience in Utilization Review specific to Workers Compensation is a plus.


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