Evaluates workers’ compensation treatment requests for medical necessity, appropriateness, and regulatory compliance. Applies evidence-based guidelines, performs prospective, concurrent, retrospective, and appeal reviews, gathers clinical information, communicates determinations with providers, and refers cases for physician review. Maintains productivity, turnaround-time, confidentiality, and quality standards while managing utilization review processes independently.
Medata, a company of Medrisk is seeking Initial Clinical Reviewers to join our Utilization Review Program. The Initial Clinical Reviewer will be responsible for evaluating medical treatment requests to determine medical necessity, appropriateness and compliance with applicable workers’ compensation guidelines and regulations. This role involves collaboration with healthcare providers, employers, therapist and attorneys to ensure timely and accurate utilization review determinations.
Duties:
- Review and evaluate requests for medical treatment and services under workers’ compensation claims
- Collect additional relevant data as needed with regard to determining medical necessity
- Apply evidence-based clinical guidelines and state regulations to determine medical necessity
- Perform Prospective, Concurrent, Retrospective and Appeal level reviews as assigned
- Communicate with providers regarding clinical determinations and requests for additional information
- Refer requests requiring physician review based upon utilization review protocols
- Meet productivity, turnaround time and quality audit standards
- Maintain knowledge of internal processing standards and workers’ compensation regulations
Requirements/ Skills/ Qualifications:
- Active, unrestricted clinical license (RN, LVN, LPN)
- Minimum of two years of clinical experience providing direct patient care
- Minimum of one year of utilization review experience, preferably workers’ compensation
- Knowledge of workers’ compensation, utilization review processes and treatment guidelines
- Excellent written and verbal communication skills
- Knowledge of medical/clinical guidelines (ODG, Interqual, Milliman, ACOEM or state –specific guidelines)
- Knowledge of ICD10, CPT codes
- High comfort level with computers and computer programs (MS Word, MS Excel, Email)
- Ability to maintain confidentiality
- Strong Organizational Skills
- Ability to work independently with minimal supervision
- Ability to meet deadlines in a fast paced, time sensitive environment
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