Medical Reviewer - CT08BE
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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.
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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
- Decision making skills
- Communication skills
Additional information:
This role will have the expectation of working in an office (Hartford, CT or Alpharetta, GA) 5 days a week (Monday - Friday).
Compensation
The listed annualized base pay range is primarily based on analysis of similar positions in the external market. Actual base pay could vary and may be above or below the listed range based on factors including but not limited to performance, proficiency and demonstration of competencies required for the role. The base pay is just one component of The Hartford's total compensation package for employees. Other rewards may include short-term or annual bonuses, long-term incentives, and on-the-spot recognition. The annualized base pay range for this role is:
$64,160 - $96,240
Equal Opportunity Employer/Females/Minorities/Veterans/Disability/Sexual Orientation/Gender Identity or Expression/Religion/Age
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