Utilization Review Specialist

Department: Claims Administration & Adjusting

Employment Type: Permanent - Full Time

Location: Atlanta, GA

Reporting To: Karen Shaffer

Compensation: $65,000 - $75,000 / year

Description

Key Responsibilities

• Perform precertification reviews using accepted medical criteria in accordance with URAC standards and state-mandated timeframes
• Ensure medical requests are causally related to reported injuries and submitted by authorized treating providers
• Forward cases that do not meet established criteria to peer review physicians
• Prepare and pose appropriate clinical questions to peer review physicians, incorporating concerns from adjusters and/or telephonic case managers
• Coordinate and facilitate peer-to-peer telephonic reviews, precertification, concurrent reviews, appeals, and retrospective reviews
• Complete final determinations and reports upon receipt of peer physician recommendations and communicate outcomes to all appropriate parties
• Accurately document all medical, clinical, and contact information in the computerized case management system
• Draft, edit, and revise correspondence and determination letters in accordance with established protocols
• Ensure compliance with URAC criteria and internal policies and procedures
• Maintain strict confidentiality of all patient, provider, and case-related information in compliance with state and federal regulations
• Serve as a patient advocate while adhering to all legal, ethical, and regulatory standards
• Participate in committees such as Quality Assurance, Grievance, or other committees as assigned
• Negotiate fees with providers or refer cases to alternate vendors when appropriate
• Perform other duties as assigned
  
  

Skills, knowledge & expertise

• Registered Nurse (RN) with a minimum of three (3) years of clinical experience across varied hospital specialty units, including but not limited to ER, ICU/CCU, Surgery, Trauma, Orthopedics, Neurology, and/or Psychiatry
• Minimum of two (2) years of Utilization Review experience in Workers’ Compensation, Health & Accident, or Auto Liability (preferred)
• Utilization Review certification such as CPUR or ABQUARP (preferred)
• Proof of current, unrestricted state RN licensure or multi-state compact licensure
• Strong working knowledge of Workers’ Compensation laws and managed care arrangements
• Ability to work independently with minimal supervision in a fast-paced environment
• Proficiency with computers, utilization review systems, and standard business software
• Excellent written and verbal communication skills
• Strong organizational, documentation, and time-management skills
• Collaborative team player with strong customer service orientation
• Commitment to maintaining current knowledge of industry trends, regulations, and standards
  
  

Benefits

• Medical, dental, and vision plans to ensure your health and that of your family.
• A 401k plan with employer matching to help you build a secure financial future.
• Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
• Paid holidays.
• Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.