Clinical Reviewer

3 weeks ago

Hartford, Connecticut, United States The Hartford Full time

We're seeking a skilled Clinical Reviewer to join our team at The Hartford. As an Initial Clinical Reviewer, you will play a critical role in evaluating treatment requests for medical necessity and appropriateness.

Key Responsibilities:

  • Evaluate treatment or service requests for medical necessity and appropriateness using nursing judgment, treatment criteria guidelines, and Physician Advisor/Peer Clinical Review referral process.
  • Conduct first-level prospective, concurrent, or retrospective review, employing standardized evidence-based review criteria and treatment parameters to authorize services.
  • Negotiate alternative treatment plans within treatment criteria guidelines.
  • Determine medical necessity, intensity of service, and setting according to regulatory and ethics requirements.
  • Comply with URAC Workers' Compensation Utilization Management Standards and Policy and Procedures.
  • Maintain injured worker privacy, confidentiality, and safety, advocacy, adherence to ethical and legal standards.
  • Process utilization review determinations within required jurisdictional and URAC timeframes.
  • Accurate use of all correspondence within regulatory, URAC, and Utilization Review Policy and Procedure requirements.
  • Demonstrate appropriate network utilization in accordance with regulatory requirements.
  • Oversight of any delegated tasks.

Qualifications:

  • RN/Nurse with current unrestricted state licensure required.
  • Bachelor's or higher degree in a health-related field preferred.
  • CCM, CRC, CDMS, or similar certification preferred; a plus.
  • 3 years clinical practice experience with orthopedic, neurological, rehabilitation, medical/surgical, or occupational health preferred.
  • 2 years workers' compensation utilization management or case management experience preferred.
  • Basic computer proficiency (Microsoft Office Products including Word, Outlook, Excel, PowerPoint); which includes navigating multiple systems.
  • Ability to effectively communicate telephonically and in written form.
  • Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.
  • Ability to synthesize large volumes of medical records and facilitate multi-point care coordination.
  • Must meet productivity and quality expectations.
  • Ability to organize and prioritize daily work independently and effectively.

About The Hartford:

We're a leading insurance company that goes beyond coverage and policies. We're committed to making a difference and helping our customers, communities, and employees succeed. Our team is dedicated to evaluating future financial risks and developing innovative solutions to protect our customers.

Why Work at The Hartford:

We offer a total compensation package that includes short-term or annual bonuses, long-term incentives, and on-the-spot recognition. Our annualized base pay range for this role is $64,160 - $96,240. We're an equal opportunity employer and welcome diverse candidates to join our team.

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