Description

Utilization Review is a collaborative process to promote quality cost effective outcomes, which enhance the physical, psychosocial, and vocational health of individuals. The Health Care Professional applies and provides technical and clinical knowledge and experience to the field of utilization management to assess the medical necessity of provider requests for services. The UR HCP will be able to apply evidence-based guidelines applicable to the jurisdiction for the claim.

Position Logistics: Non-Exempt, Full-time or Part-Time, Monday – Friday, 8-hour workdays, between 8:30am – 6:00 pm Pacific Standard time, Work from local offices (Rocklin, CA)

Responsibilities may include, but are not limited to:

• Assessment
  • Perform a complete evaluation of the medical data for the request
  • Collect additional relevant data as needed to decide on medical necessity
  • Analyze the collected data to determine medical necessity as per evidence-based guidelines
• Planning
  • Discuss the analyzed data and the comprehensive plan of care with the insurance representative prior to implementation as needed
  • Upon authorization, provide notification of decision to provider, requester, claimant, carrier, and all other parties as mandated by law
• Implementation
  • Coordinates information between all parties (injured worker, physicians, employer, other providers, such as therapists, and attorney, if any are involved)
• Evaluation
  • Participate in annual audits of work product to ensure compliance
• Professional interaction with EKHS staff, members of the medical community, and all customers of EKHS; both in oral and written forms
• All work is done within the scope of practice of an RN, DC, PT, DPT, LVN, OT, or LAc

Pay, Benefits & Perks:

• Position starts at $30-32 per hour based on experience, education, certification.
• 401K

Requirements

• Graduate of an accredited school of nursing, chiropractic, or another related medical program (RN, DC, PT, DPT, LVN, OT, LAc)
• Valid state-specific license in the appropriate scope of practice in good standing with no restrictions
• Possesses and can demonstrate the professional and technical skills required
• Experience in UR, Workers' Compensation experience highly preferred, but not required
• Excellent Written and Oral Communication Skills
• High comfort level with computers and computer programs (MS Word, MS Excel, Email)