Overview:
Medata is seeking Initial Clinical Reviewers to work in our utilization review program. UR is a collaborative process to promote quality outcomes, which enhance the physical, psychosocial, and vocational health of individuals. The Initial Clinical Reviewer applies and provides technical knowledge and experience to the field of utilization management to assess the medical necessity of provider requests for services.
Duties:
- Perform an evaluation of the medical data for utilization review requests.
- Collect additional relevant data as needed with regard to determining medical necessity.
- Analyze the collected data to apply evidence-based guidelines.
- Upon authorization, provide notification of decision to provider, requester, claimant, carrier, and all other parties as mandated by law.
- Coordinates information between all parties (injured worker, physicians, employer, therapists, attorney, etc)
- Participate in audits of work product to insure compliance.
Requirements/Skills/Qualifications:
- Graduate of an accredited school
- Valid current LVN, LPN, RN, license in good standing
- Possesses and can demonstrate the professional and technical skills of a Registered Nurse, LVN, LPN.
- Has professional experience in providing direct patient care and has undergone formal training in a health care field.
- Excellent Written, Oral, and Interpersonal Communication Skills.
- Must be able to maintain confidentiality.
- Strong Organization Skills.
- High comfort level with computers and computer programs (MS Word, MS Excel, Email)
- Ability to work independently with minimal supervision
- Ability to meet deadlines in a fast paced, time sensitive environment
Preferences:
- Experience in Utilization Review, Workers’ Compensation experience strongly preferred
- Knowledge of Medical/Clinical Guidelines, such as Milliman, ACOEM, ODG, and /or InterQual
- Compact License