Health Care Professional – Utilization Review / First-Level Reviewer
About The Position
The Health Care Professional performs first-level utilization review of treatment authorization requests for injured workers. The HCP reviews clinical documentation and applies California’s Medical Treatment Utilization Schedule (MTUS) and other applicable evidence-based guidelines to determine whether requested treatment meets criteria for authorization. The HCP may approve treatment requests when applicable criteria are satisfied. Requests that cannot be approved at first-level review are prepared and referred to the appropriate Physician Reviewer. The HCP does not modify or deny Requests for Authorization. All modification and denial decisions are made by Physician Reviewers.
Requirements
- Active, unrestricted California professional license as an LVN, RN, or DC.
- Must reside and work in California.
- Clinical experience relevant to your licensed discipline and the clinical services being reviewed.
- Strong clinical assessment, critical-thinking, analytical, and problem-solving skills.
- Excellent written and verbal communication skills.
- Strong attention to detail, organization, and time-management skills.
- Ability to work independently and manage multiple priorities and deadlines.
- Ability to navigate multiple software systems concurrently.
- Proficiency with Microsoft Office and web-based platforms.
- Minimum typing speed of 45 WPM.
- Ability to perform extensive telephone- and computer-based work.
Nice To Haves
- Three or more years of relevant clinical experience is preferred.
- Previous workers’ compensation experience.
- Previous utilization review or utilization management experience.
- Experience in occupational medicine, orthopedics, neurology, rehabilitation, musculoskeletal care, acute care, case management, occupational health, disability management, or another relevant clinical specialty.
- Familiarity with MTUS and evidence-based treatment guidelines.
- Relevant professional certification or advanced credential appropriate to your discipline.
Responsibilities
- Review Requests for Authorization and supporting medical documentation for completeness.
- Apply MTUS and other applicable evidence-based clinical guidelines.
- Determine whether sufficient clinical information is available to complete the review and request additional information when necessary.
- Make first-level review determinations within applicable regulatory timeframes.
- Approve treatment requests when applicable criteria are satisfied.
- Communicate professionally with requesting providers to obtain additional information and discuss treatment requests as appropriate.
- Prepare and refer cases that cannot be approved at first-level review to the appropriate Physician Reviewer.
- Review additional medical information received in connection with reconsiderations.
- Identify and appropriately process duplicate Requests for Authorization.
- Maintain accurate and timely documentation of utilization review activity.
- Ensure required communications and regulatory timeframes are met.
- Manage multiple reviews, priorities, and deadlines in a fast-paced remote work environment.
Benefits
- Overtime eligible in accordance with applicable California law
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
