Utilization Review Specialist
On-siteOmaha, Nebraska, United States
Job Summary
Triage and manage intake coordination for authorization and independent medical review requests. Review authorization requests against evidence-based medical treatment guidelines, researching claim files and interpreting medical reports to apply established guidelines. Advocate for injured workers and the Claims department by ensuring proposed treatments align with diagnoses, escalating requests outside authority to specialists or nurses. Routinely contact providers to clarify treatment requests and obtain additional medical information while maintaining thorough understanding of Company policies. Establish positive partnerships with Medical Bill Review staff and cross-functional teams including adjusting staff, Special Investigations, Legal, and Client Services. Enter accurate documentation of clinical findings and determinations, ensuring appropriate notices are forwarded to providers, workers, and attorneys in compliance with State law and Company policy. Maintain patient confidentiality and safeguard protected health information per legal and policy requirements.
Required Qualifications
- Bachelor's or Associate's degree in a medical field from an accredited college or technical school
- Minimum of 6 months of relevant experience and/or training in a medical field
- Equivalent combination of education and experience
- Able to effectively use Microsoft Office/365 applications
- Able to become proficient in proprietary and vendor software applications
- Able to read and understand basic documents, including statutes, regulations, medical records, medical bills, medical resource materials, claim notes, and claim data fields
- Able to write clear, concise reports accurately conveying complex and nuanced information
- Able to write correspondence on medical and legal points
- Able to effectively present information and respond to questions with adjusting staff, Management, and others
- Able to solve practical problems and deal with a variety of variables in situations where only limited standardization exists
- Able to interpret a variety of instructions furnished in written, oral, diagram, graph, or schedule form
- Able to apply concepts such as addition, subtraction, multiplication, division, fractions, percentages, ratios, and proportions to practical situations
- Able to derive appropriate conclusions and apply on the job
- Double-checks the accuracy of information and work product to provide accurate and consistent work
- Completes all work according to procedures and standards
- Works in a conscientious, consistent, and thorough manner
- Communicates and articulates clearly; is informative and appropriately concise
- Asks questions freely to broaden knowledge and skills
- Prepares clear and concise e-mails and other basic required written communications
- Is objective; is able to evaluate facts apart from personal bias
- Identifies key decisions within area of responsibility and escalates tasks to appropriate authority as needed
- Effectively uses appropriate decision-making techniques
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