Utilization Reviewer 2

Enlyte•St. Louis, MO

10d•Onsite

About The Position

This is an In Office Position from Monday - Friday from 9 AM - 5 PM CST. MO Registered Nurse or Chiropractor License Required. We are seeking a qualified Utilization Reviewer located in the St. Louis, MO area. The ideal candidate performs utilization review on workers’ compensation related prospective, concurrent, and retrospective treatment referrals. The ideal candidate will play a crucial role in assessing and ensuring the appropriateness of medical treatment plans, contributing to effective claims management and optimal patient outcomes.

Requirements

Minimum Education: Bachelor's degree.
Registered Nurse (RN) or LVN with a valid license in the state of practice.
Minimum of 2 years of clinical experience; or an advanced degree without experience.
Knowledge of medical terminology, treatment modalities, and healthcare guidelines.
Analytical and critical thinking skills for effective decision-making.
Strong communication and interpersonal skills to liaise with diverse stakeholders.
Ability to work independently and collaboratively within a team environment.
Detail-oriented with strong organizational skills to manage multiple cases efficiently.
Familiarity with relevant software and tools used in healthcare.

Nice To Haves

Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity.
Prior experience in the workers' compensations field.

Responsibilities

Uses solid clinical judgment to ensure treatment approved is medically necessary.
Forwards treatment requests for physician reviewer that cannot be approved as medically necessary based on application of solid clinical judgment.
Collaborates with healthcare providers, claims adjusters, and other stakeholders to gather relevant information for comprehensive assessments.
Evaluates medical documentation to ensure compliance with industry standards and regulatory requirements.
Communicates findings clearly and concisely through written reports and verbal discussions.
Stays up-to-date on industry regulations, medical advancements, and best practices to enhance the quality of reviews.
Participates in team meetings and contributes to the continuous improvement of utilization review processes.