Utilization Review Nurse Specialist - GA Workers' Comp

About Us 

At Davies, we get it... you are not just looking for a job, you are looking to build a life and a career. We believe in our people and realize that our success is a direct result of creating a learning atmosphere, leadership opportunities, and promoting from within. We believe that engaging in corporate social activities and working together as a team is a vital part of the Davies culture. 

With a multinational global team, Davies Group is a specialist professional services and technology firm working in partnership with leading insurance, highly regulated, and global businesses.  At Davies Group, we help clients to manage risk, operate core business processes, and to transform and grow. We deliver operations, consulting and technology solutions across the risk and insurance value chain, including excellence in claims, underwriting, distribution, regulation, customer experience, human capital, transformation, and change management.  

Are you looking for a company that is Dynamic and Innovative where the teammates are Connected and Succeed Together?  If so, Davies may just be the right choice for you.

Job Overview

As a Utilization Review Specialist on our team, you would be responsible for precertification reviews in accordance with URAC guidelines to ensure the accuracy of accepted criteria; and to ensure the prompt coordination of appropriate care for the approved category of medical procedures.  Reporting to the Assistant Program Manager, you would also ensure that the medical procedures are medically necessary and causally related to the accidents, as reported by the injured workers of the State of Georgia, and that the request comes from the authorized treating physician.

Opportunity to work from home.

Responsibilities and Duties:

• Complete precertification of medical requests assigned by Manager or coordinator. 
• Reviews not meeting accepted criteria will be forwarded on to a Peer Review physician. 
• Pose appropriate questions to the Peer Physician to include concerns expressed by the adjuster and/or TCM.
• Upon receipt of the Peer Physician’s report, will complete final report and present recommendations to the adjuster and/or TCM.
• Complete all documentation and composition of letters as per protocol.
• Appropriately document all data received from interviews, contacts and medical records in the computerized system.
• Serve as a patient advocate adhering to all legal, ethical and accreditation/regulatory standards.
• Performing other duties as needed.

Experience and Qualifications

• RN or LPN with a minimum of three years clinical experience in varying hospital specialty units ie:  ER, ICU/CCU, Surgery, Trauma, Orthopedic, Neurology, Psychiatric.    
• RN or LPN with a minimum of two years experience in Utilization Review in the areas of Workers’ Compensation, Health and Accident or Auto Liability.
• Certification in Utilization Review, i.e.: CPUR, ABQUARP is preferred.
• Proof of current State Licensure.

Knowledge, Skills and Abilities

• Must be knowledgeable of the Workers’ Compensation laws and how they are integrated into the Managed Care Arrangement.
• Maintains knowledge of current trends, standards and law changes.
• Must be self-directed and able to work independently.
• Ability to effectively and efficiently operate a personal computer and related claims and business software. 
• Superb communication skills, verbal and written, conducted in a timely manner.

Diversity and Inclusion 

Davies is committed to being a diverse and inclusive workplace. We welcome candidates of all genders, gender identity and expression, neurodiversity, sexual orientation, disability, physical appearance, body size, race, age, nationality, and belief (or lack thereof). 

Rewards and Recognition 

We embrace innovation and run an annual competition available for all colleagues to submit their ideas. The top finalists travel to the current year’s competition site where they pitch their ideas to our investors. The winner receives funding to bring their idea to life and the runners up receive a reward for their involvement. Some of our teammates have moved across into brand new positions to further develop their ideas/projects!