Utilization Review Specialist
Summary
Reviews workers' compensation medical treatment requests for appropriateness using evidence-based guidelines and state laws, coordinating with providers and claims teams.
Berkshire Hathaway Homestate Companies, Workers Compensation Division, has an opening for a Utilization Review Specialist in Omaha to join its Medical Management team. The individual ensures that medical treatment requests from providers are medically appropriate and reviewed in compliance with State laws and Company policies.
ESSENTIAL RESPONSIBILITIES
- Triages and manages intake coordination of requests for authorization and independent medical review requests.
- Reviews authorization requests for approval in accordance with evidence-based medical treatment guidelines.
- Researches claim files in relation to the requested medical treatment, interprets medical reports while utilizing critical thinking, and applies appropriate established guidelines to requested treatment.
- Advocates for the injured worker and Claims department, ensuring proposed treatment requests are appropriate for the diagnosis.
- Escalates treatment requests outside of authorization authority for review by a Utilization Review Specialist 2 or Utilization Review Nurse.
- Ensures that utilization review processes are performed in accordance with the time limits and other requirements set by State law and Company policy.
- Routinely contacts providers to clarify treatment requests and examination findings, as well as to obtain additional medical information as needed.
- Gains and Maintains a thorough understanding of Company policies regarding the review of authorization requests by Utilization Review Specialists.
- Establishes and maintains a close, positive communicative relationship and working partnership with Medical Bill Review staff to ensure effective and efficient integrated medical management of treatment provided to injured workers.
- Fosters a positive and close working relationship with other Company staff, including adjusting staff, other Medical Management staff, Special Investigations Unit, Legal, Liens, Customer Care, and Client Services.
- Maintains patient confidentiality and safeguards protected health information in accordance with State and Federal laws and Company policies.
- Enters clear, concise, and accurate documentation of requested medical treatments, to include clinical findings, treatment guidelines, and determinations.
- Ensures that appropriate notices are forwarded to medical providers, injured workers, Claims staff, and attorneys.
- Provides general office or administrative support throughout the department.
QUALIFICATIONS
- EDUCATION: Bachelor's or Associate's degree in a medical field from an accredited college or technical school required.
- EXPERIENCE: Minimum of 6 months of relevant experience and/or training in a medical field, or equivalent combination of education and experience, required.
- TECHNICAL SKILLS: Able to effectively use Microsoft Office/365 applications and able to become proficient in proprietary and vendor software applications.
- LANGUAGE ABILITY: 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, as well as correspondence on medical and legal points. Able to effectively present information and respond to questions with adjusting staff, Management, and others.
- MATH AND REASONING ABILITY: 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. Ability to derive appropriate conclusions and apply on the job.
CORE COMPETENCIES
ATTENTION TO DETAIL
• 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.
COMMUNICATION
• 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.
PROBLEM SOLVING & DECISION MAKING
• 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.
• 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.
COMMUNICATION
• 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.
PROBLEM SOLVING & DECISION MAKING
• 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.