Utilization Review Specialist

We are looking for a Utilization Review Specialist to join our team! The Utilization Review Specialist bridges between a Utilization Review Nurse and Pre-Clinical Coordinator providing coverage for both teams. The full UR function can be performed in applicable jurisdictions. UR Specialists can monitor the referral cue, set up the referral in Vision, evaluate medical records for completion, request additional records, complete the review process using approved evidence-based guidelines, provide determinations, and close referrals.

In this job, you will:

• Initiate and maintain appropriate verbal and/or written contacts with employers, clients, claimants, and medical providers.
• Set up files in all appropriate systems; assign files, when applicable, to the nurse
• Facilitate and schedule appointments as needed, and keep the Telephonic Nurse Case Manager (TCM), clients, claimants, providers, and employers informed verbally and/or in writing of any changes, delays, updates, or problems
• Maintain appropriate electronic and paper files
• Obtain authorization for medical release of information from the adjuster, as necessary, for records acquisition
• Interface with a variety of inter-disciplinary providers (e.g., PT, diagnostic, psychology, etc.)
• Identify, maintain, and update participating providers
• Answer incoming calls and direct the call appropriately. Responds to various written and telephonic inquiries regarding status of case
• Screen all re-open files (subsequent URs) to determine duplicate requests, vs. an appeal request that is beyond the allotted timeframe, vs. a reconsideration, vs. a new UR
• Basic invoicing at completion of UR process.
• Review medical records for completion and request additional records as needed to process the UR request.
• Using approved evidence-based guidelines to determine if treatment request is medically necessary. If guidelines are not met, process request for Peer or Physician Review
• Write nurse summaries on all UR files
• Document properly in Rising's database (and client databases when appropriate), and send determination letters on each completed UR
• Track the ongoing status of all UR activity so that appropriate turn-around times are met
• Maintain organized files containing clinical documentation of interactions with all parties of every claim
• Utilize good clinical judgment, careful listening, and critical thinking and assessment skills

Requirements

• Certificate/diploma from state approved LPN/LVN program.
• Hold a current, active LPN/LVN license in one or more states relevant in applicable jurisdiction and in accordance to Rising Licensing and Certification policy
• 1 year of clinical experience
• The ability to set priorities and work both autonomously and as a team member
• Well-developed time-management, organization, and prioritization skills
• Excellent analytical skills
• Superb oral and written communication
• The ability to gather data, compile information, and prepare summary reports
• Strong interpersonal and conflict resolution skills
• Experience in a fast-paced, multi-faceted environment
• Demonstrated persistence and attention to detail
• General understanding of CPT and ICD-9/ICD-10 codes and Medicare guidelines
• Working knowledge of: Microsoft Word, Excel, and Outlook
• Ability to remain calm during stressful situations
• A customer-service mindset

Preferred:

• 3 to 5 years of clinical practice experience or 2 years of UR experience.
• More than one state license
• Experience with Workers' Compensation, short-term or long-term disability, or liability claims

Benefits

• Hourly Rate: $28.00-32.00
• Profit sharing, 401k matching, generous time off, and career growth opportunities
• A relaxed, yet upbeat, work environment, with a jeans professional dress code
• Rising was named a Top Workplace in the healthcare industry for 2023! Check out our profile here: Rising Medical Solutions, Inc Profile (topworkplaces.com)
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If you are ready to join a team of professionals dedicated to making a difference and making lives better, please apply today!