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Davies Talent Solutions · 2 weeks ago

Utilization Review Specialist

United States

Contract

Remote

Mid Level

3+ years exp

Davies Talent Solutions is partnering with an insurance organization seeking an experienced Utilization Review Specialist who will perform precertification reviews in accordance with URAC guidelines. The role focuses on verifying medical necessity and compliance with state-mandated utilization review timeframes while facilitating various types of reviews and ensuring prompt coordination of appropriate care for approved procedures.

ConsultingManagement ConsultingRecruiting

Diversity & Inclusion

Responsibilities

Perform precertification reviews using accepted criteria and URAC guidelines

Ensure medical procedures are causally related to the reported accident and requested by an authorized treating physician

Coordinate Peer Reviews and facilitate Peer-to-Peer Telephonic Reviews

Handle Precertification, Concurrent Reviews, Appeals, and Retrospective Peer Reviews

Meet all state-mandated utilization review timeframes and Medical Management standards

Document all data from interviews, contacts, and medical records in the system

Compose and revise correspondence and reports per protocol

Maintain patient privacy and adhere to all legal, ethical, and regulatory standards

Serve as a patient advocate and participate in committees such as Grievance and Quality Assurance

Negotiate fees with providers or channel cases to vendors as appropriate

Qualification

Utilization Review experienceActive RNLPN licenseWorkers’ Compensation knowledgeURAC criteria familiarityClaims systems proficiencyBusiness software proficiencyMembership in UR organizationsCommunication skillsOrganizational abilityAttention to detailTeamwork abilityIndependent work ability

Required

Active Georgia RN or LPN license with a minimum of 3 years of clinical experience in hospital specialty units (ER, ICU/CCU, Surgery, Trauma, Orthopedic, Neurology, Psychiatric)

Proof of current State Licensure or Multi-state Licensure

Strong knowledge of Workers' Compensation laws and integration into Managed Care arrangements

Familiarity with URAC criteria

Excellent communication skills (oral and written), organizational ability, and attention to detail

Ability to work independently and as part of a team

Proficiency in claims systems and business software

Preferred

Minimum 2 years of Utilization Review experience in Workers' Compensation, Health and Accident, or Auto Liability

Certification in Utilization Review (CPUR, ABQUARP)

Active membership in local Utilization Review organizations

Company

Davies Talent Solutions

Part of Davies, the leading specialist professional services & technology business serving insurance, financial services and highly regulated markets.

Founded in 2009

Haywards Heath, West Sussex, GBR

51-200 employees