Initial Clinical Reviewer

Summary of Functions: The Initial Clinical Reviewer will apply and provide technical knowledge and experience to the field of utilization management to assess the medical necessity of provider requests for services. Essential Duties and Responsibilities: · Reports to Vice President of Managed Care · Responsible for performing prospective, concurrent, and retrospective utilization management activities as per specified state UR guidelines by utilizing clinical expertise, judgment, and established medical criteria · Determine whether to authorize medical treatment or escalate to an appropriate physician specialist and provide rationale for doing so · Manages and follows relevant time frame standards for conducting and communicating utilization review determinations · Maintain knowledge of and is compliant with state specific UR guidelines · Prepare and maintain accurate quality data on all utilization management activities · Ensures the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards · Collaborate with the IMS UR team and participate in regular department and committee meetings as appropriate · May provide guidance and coaching to other initial clinical reviewers and participate in the orientation of newly hired initial clinical reviewers · Answers Utilization Management directed telephone calls; managing them in a professional and competent manner Qualifications: · Graduate of an accredited school of nursing · Current RN or LPN/LVN license to practice as a health professional in a state or territory of the United States and the license is recognized in the relevant jurisdiction · License is unrestricted, and if restricted that is allowed by relevant jurisdiction it is of the type that does not affect the ability to fulfill the roles and responsibilities of the position · Minimum of three years of clinical experience · Possesses and can demonstrate the professional and technical skills of an RN and/or LPN/LVN · Minimum of two years of prior experience in Utilization Review, Workers' Compensation experience strongly preferred · Excellent Written and Oral Communication Skills · Excellent Interpersonal Skills · Strong Organization Skills · High comfort level with computers and computer programs (MS Word, MS Excel, Email) · Ability to work independently with minimal supervision · Ability to meet deadlines in a high pressure, time sensitive environment Physical Demands: · Regularly required to sit; use hands and fingers, and talk · Frequently required to reach with hands · Occasionally lift and/or move up to 20 lbs. · Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust Work Environment: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Pay: $62,000.00 - $82,000.00 per year Benefits: • 401(k) • 401(k) matching • Dental insurance • Flexible spending account • Health insurance • Health savings account • Life insurance • Paid time off • Vision insurance Education: • Bachelor's (Preferred) Experience: • Utilization review: 2 years (Required) License/Certification: • RN License (Required) • LPN (Preferred) Location: • South Carolina (Required) Work Location: Remote Apply tot his job