Health Care Professional – Utilization Review / First-Level Reviewer
$87,360–$93,600 year
RemoteCalifornia, United States
Job Summary
Review Requests for Authorization and supporting medical documentation for completeness, applying MTUS and evidence-based clinical guidelines to determine treatment eligibility. Make first-level review determinations within regulatory timeframes, approving requests when criteria are satisfied or requesting additional information when necessary. Prepare and refer cases that cannot be approved at first-level review to the appropriate Physician Reviewer, while managing multiple reviews, priorities, and deadlines in a fast-paced remote work environment. Maintain accurate and timely documentation of utilization review activity and ensure required communications and regulatory timeframes are met.
Required Qualifications
- Active, unrestricted California professional license as an LVN, RN, or DC
- Must reside and work in California
- Three or more years of relevant clinical experience
- Strong clinical assessment, critical-thinking, analytical, and problem-solving skills
- Excellent written and verbal communication skills
- Strong attention to detail, organization, and time-management skills
- Ability to work independently and manage multiple priorities and deadlines
- Ability to navigate multiple software systems concurrently
- Proficiency with Microsoft Office and web-based platforms
- Minimum typing speed of 45 WPM
- Ability to perform extensive telephone- and computer-based work
Desired Qualifications
- Previous workers' compensation experience
- Previous utilization review or utilization management experience
- Experience in occupational medicine, orthopedics, neurology, rehabilitation, musculoskeletal care, acute care, case management, occupational health, disability management, or another relevant clinical specialty
- Familiarity with MTUS and evidence-based treatment guidelines
- Relevant professional certification or advanced credential appropriate to your discipline
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