Utilization Review Specialist

Location: Omaha, Nebraska, United States; hybrid workplace

Company

hirify.global' Workers Compensation Division provides workers' compensation insurance and medical management services.

What you will do

• Coordinate intake and triage of authorization and independent medical review requests.
• Review treatment requests using evidence-based medical treatment guidelines, state laws, and company policies.
• Research claim files, interpret medical reports, assess diagnoses and proposed treatment, and document clinical findings and determinations.
• Contact providers to clarify requests and obtain additional medical information.
• Escalate requests outside the role's authorization authority to Utilization Review Specialist 2 or Utilization Review Nurse.
• Coordinate with claims, medical bill review, legal, customer care, and other departments while protecting patient confidentiality.

Requirements

• Associate's or bachelor's degree in a medical field from an accredited college or technical school.
• At least 6 months of relevant medical experience or training, or an equivalent combination of education and experience.
• Ability to use Microsoft Office/365 and learn proprietary and vendor software.
• Ability to read and interpret statutes, regulations, medical records, medical bills, medical resources, claim notes, and claim data.
• Ability to write clear, accurate reports and correspondence covering complex medical and legal information.
• Strong attention to detail, objective problem-solving, communication, and decision-making skills.

Culture & Benefits

• Hybrid work environment in the Medical Management department.
• Collaborative work with claims, medical bill review, legal, investigations, customer care, and client services teams.
• Work governed by established procedures, state and federal requirements, and company policies.
• Responsibility for maintaining patient confidentiality and safeguarding protected health information.