Initial Clinical Reviewer

Medical Reviewer - CT08BE

We’re determined to make a difference and are proud to be an insurance company that goes well beyond coverages and policies. Working here means having every opportunity to achieve your goals – and to help others accomplish theirs, too. Join our team as we help shape the future.   

         

The Clinical team is seeking an Initial Clinical Reviewer.  This is a 100% in office position (Hartford, CT or Alpharetta, GA) that will perform Utilization Review for Workers’ Compensation Claims.  An Initial Clinical Reviewer (ICR) is responsible for evaluating treatment requests in accordance with jurisdictional regulations.  An ICR utilizes jurisdictional treatment guidelines as well as standardized evidence-based criteria to ensure treatment that is requested is necessary and medically appropriate for the compensable injury.  Clinical judgement and critical thinking is utilized to achieve optimum, cost-effective treatment while partnering with claim partners, vendors, and healthcare providers.  

 

Key responsibilities include: 

Evaluate treatment or service requests for medical necessity and appropriateness using nursing judgment, treatment criteria guidelines and Physician Advisor/Peer Clinical Review referral process.  

Conduct first level prospective, concurrent, or retrospective review, employing standardized evidence-based review criteria and treatment parameters to authorize services. Identify cases where additional information is required to complete the review and/or identify potential medical necessity cases. Negotiate alternative treatment plans within treatment criteria guidelines.  

• Determine medical necessity, intensity of service, and setting according to regulatory and ethics requirements. 

• Comply with URAC Workers’ Compensation Utilization Management Standards and Policy and Procedures. 

• Comply with URAC Standards and Policy and Procedures. 

• Maintain injured worker privacy, confidentiality and safety, advocacy, adherence to ethical and legal standards. 

• Process utilization review determinations within required jurisdictional and URAC timeframes. 

• Accurate use of all correspondence within regulatory, URAC and Utilization Review Policy and Procedure requirements. 

• Demonstrate appropriate network utilization in accordance with regulatory requirements.

• Oversight of any delegated tasks. 

• This position will also be cross trained in Drug Review. 

 

 Qualifications:

• RN / Nurse with current unrestricted state licensure required.

• Bachelor’s or higher degree in a health-related field preferred.  

• CCM, CRC, CDMS or similar certification preferred; a plus.

• 3 years clinical practice experience with orthopedic, neurological, rehabilitation, medical/surgical or occupational health preferred. 

• 2 years workers’ compensation utilization management or case management experience preferred.    

• Basic Computer proficiency (Microsoft Office Products including Word, Outlook, Excel, Power Point); which includes navigating multiple systems. 

• Ability to effectively communicate telephonically and in written form. 

• Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor.  

• Ability to synthesize large volumes of medical records & facilitate multi-point care coordination. 

• Must meet productivity & quality expectations. 

• Ability to organize and prioritize daily work independently and effectively. 

Additional Competencies: 

• Strategic thinking 

• Customer focus 

• Business knowledge 

• Problem solving 

• Collaboration – partnership