Description

The UM Reviewer I applies professional clinical knowledge to review medical information to determine if requested treatment is medically necessary and appropriate to support the resolution of the claim.

• Bachelor of Science in Nursing or related clinical degree preferred. Must hold an RN or RPT License.
• Minimum of three (3) years diverse clinical experience or prior experience in managed care/workers compensation.
• Possess clinical training and knowledge consistent with RN or RPT licensure
• Ability to make independent clinical decisions within the scope of RN/RPT licensure.
• Ability to work in an unstructured environment with staff located remotely throughout the country.
• Must have strong written and verbal communication skills, as well as the ability to work well within a team environment.
• Must have strong organizational skills.
• Working knowledge of personal computers with the ability to use standard word processing software applications.
• Must possess a current, professional Registered Nurse or Registered Physical Therapy License to practice as a health professional in a state or territory of the United States with a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review.
• Current RN home state licensure in good standing without restrictions with the State Board of Nursing.

#LI-RG1

• Uses clinical RN or RPT training and knowledge to render authorization decisions of medical necessity of requested medical treatment
• Analyzes medical information and applies clinical knowledge and established criterion to facilitate the utilization review process
• Researches, reviews and prepares medical information to present and collaborate objectively with Broadspire Peer Physicians in order to facilitate case resolution
• Communicates with physician providers and physician peer reviewers, nurse case managers, claim examiners, attorneys, clients as necessary to clarify clinical/claim issues to facilitate the UR process
• Independently makes decisions related to the management of each UR request based on clinical expertise, State/URAC/ Client requirements
• Plans and organizes individual caseload to meet URAC and Jurisdictional regulatory requirements for timelines, notifications and documents
• Utilized appropriate desktop resources to perform the utilization review process
• Collaborates and communicates effectively to promote the integration of all Broadspire Departments and products through interdepartmental referrals and communications
• Documents pertinent information in internal and external communications to support Utilization Management determinations and case resolution
• Ability to be flexible to meet department expectations and/or business needs.
• Perform other duties as assigned
• Upholds the Crawford Code of Business Conduct at all times
• Plans and organizes individual caseload to meet Massachusetts regulatory requirements for timelines, notifications and documents