Mitchell International, Inc.

Nurse Reviewer, Utilization

US-TX
Job ID
17-7859
Type
Regular Hire

Company Overview

Mitchell International, Inc. is a leading provider of information and workflow solutions to the Property & Casualty Claims Industry and their supply chain partners. We solve interesting and complex problems that directly affect the customers our clients serve. We are constantly adapting to stay on the forefront of emerging technologies and we work diligently to maintain our position as a thought leader within our industry.

 

Mitchells workers compensation national managed care program offers solutions for insurance carriers, third-party administrators and employers. We recommend an integrated suite of solutions that include utilization review and case management with a focus on managing total claims costs while expediting safe return to work.

 

Job Description

WCS

Performs utilization review on workers compensation related prospective, concurrent and retrospective treatment referrals. Applies medical review criteria and uses solid clinical judgment to ensure treatment approved is medically necessary. Forwards treatment requests for physician reviewer that cannot be approved as medically necessary based upon application of medical review criteria and solid clinical judgment and provides QA review of completed physician reviews.

 

Responsibilities:

  • Reviews requested treatment/procedures within Mitchell utilization review policies, URAC time frames or state-mandated timeframes (whichever is more restrictive) for determination of medical necessity and appropriateness.
  • Uses evidence-based, nationally recognized treatment protocols and accesses physician reviewers, as indicated, when certification/approval cannot be recommended based upon medical review criteria or clinical experience.
  • Facilitates communication of quality determinations verbally and/or in writing with required parties in accordance with Mitchell International policies and procedures.
  • Provides leadership, oversight and guidance to team members to ensure quality product for customers.
  • Maintains ongoing communication with the claims examiner/adjustor as to status of determination.
  • Acts as a clinical resource to non-clinical staff.
  • Stays abreast and complies with state/federal legislation as it applies to utilization management services.
  • Understands and complies with applicable URAC workers’ compensation utilization management standards.
  • Stays abreast of healthcare industry current practices and trends.

 

 

Qualifications

WCS

  • Current, unrestricted RN, LPN, or LVN license required.
  • One or more years’ experience in utilization review in workers' compensation and/or medical cost containment preferred. 
  • Prior experience must include at least 3 years direct patient care.
  • Knowledge and understanding of the property/casualty insurance industry and healthcare delivery system preferred.
  • Must be able to work independently, but also work well within a team setting to achieve the highest quality results and outstanding customer service.
  • Well-developed communication, verbal and written, plus strong interpersonal skills are required.
  • Must be computer proficient with hardwired home office station. 

 

*Requires DSL, fiber or cable internet connection from home. 1 mbps preferred or better.*

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