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
Similar Jobs
Other • Utilities
As a Client Partner in Enterprise Sales, you will develop sales strategies for enterprise clients, build executive relationships, and drive high-value deal closures while maintaining accurate sales records.
Top Skills:
Technology SolutionsTelecomWireless Services
Artificial Intelligence • Big Data • Healthtech • Machine Learning • Analytics • Biotech • Generative AI
Field-based Medical Science Liaison supporting oncology commercial and educational objectives. Educates healthcare providers and key opinion leaders on Tempus oncology assays, genomic testing, and scientific data; supports sales teams, trains internal stakeholders, attends conferences, summarizes research, and shares market intelligence. Requires oncology and molecular testing knowledge, strong communication skills, existing oncology KOL relationships, an advanced scientific or medical degree, and travel up to 50%.
Top Skills:
AICapClia-88Genomic TestingLaboratory-Developed Testing (Ldt)Molecular Oncology
Cloud • Information Technology • Security • Software • Cybersecurity
Build and manage enterprise customer relationships, including C-suite stakeholders; develop strategic account plans; collaborate with internal teams; and serve as a trusted advisor aligning security solutions with business goals. The role requires full-cycle software or security sales experience, enterprise and C-level selling expertise, Texas residency, and demonstrated adoption of AI tools. Preferred qualifications include net-new logo acquisition, strategic sales planning, quota achievement, and channel partnership experience.
Top Skills:
Ai ToolsSaseZscaler Zero Trust Exchange
What you need to know about the Seattle Tech Scene
Home to tech titans like Microsoft and Amazon, Seattle punches far above its weight in innovation. But its surrounding mountains, sprinkled with world-famous hiking trails and climbing routes, make the city a destination for outdoorsy types as well. Established as a logging town before shifting to shipbuilding and logistics, the Emerald City is now known for its contributions to aerospace, software, biotech and cloud computing. And its status as a thriving tech ecosystem is attracting out-of-town companies looking to establish new tech and engineering hubs.
Key Facts About Seattle Tech
- Number of Tech Workers: 287,000; 13% of overall workforce (2024 CompTIA survey)
- Major Tech Employers: Amazon, Microsoft, Meta, Google
- Key Industries: Artificial intelligence, cloud computing, software, biotechnology, game development
- Funding Landscape: $3.1 billion in venture capital funding in 2024 (Pitchbook)
- Notable Investors: Madrona, Fuse, Tola, Maveron
- Research Centers and Universities: University of Washington, Seattle University, Seattle Pacific University, Allen Institute for Brain Science, Bill & Melinda Gates Foundation, Seattle Children’s Research Institute
