Mitchell International, Inc.

  • Nurse Reviewer, Utilization 3

    Job Location US-WY
    Job ID
    18-8384
    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.

     

    Mitchell’s Pharmacy Solutions division provides critical Pharmacy Benefit Management solutions to hundreds of workers’ compensation and auto insurance carriers, administrators and employers in the United States, as well as connects with over 65,000 pharmacies to provide injured patients with access to prescription medicines. Our mission is to provide our customers with better claim outcomes and help patients restore their lives after a workplace or automobile accident.  Mitchell’s Salt Lake City office includes over 200 associates who work directly with pharmacies and payers to process over 1 million pharmacy transactions each year.  Mitchell is the fastest growing pharmacy solutions provider to the U.S. property and casualty industry and is rapidly growing its Salt Lake City office location.  The company offers a competitive compensation and benefits package including health insurance, 401(k), disability protection and tuition reimbursement. Our associates enjoy excellent career growth opportunities in a collaborative and engaging professional office environment that includes an onsite gym, full cafeteria and available on-site day care for children.

    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.

     

     

     

    ACS (third party)

     

    As a Nurse Reviewer with Mitchell you will perform utilization review on various Third Party auto insurance related retrospective treatment referrals.  You will read complete medical claim files and construct a summarization and analysis of the treatment rendered to the injured party. You will communicate with claims adjusters at times and bill review team members to ensure adequate application of any appropriate guidelines and reviews decisions. You will apply nursing knowledge and utilize medical review criteria and solid clinical judgment to ensure treatment approved is medically necessary. You will also act as a point of contact for escalated customer concerns.  

    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. 

     

    ACS (third party)

    • Knowledge: You are a seasoned, experienced professional with a full understanding of utilization review. You will work one case at a time with approximately 23-30 cases a month. A clinical background related to trauma, orthopedic, physical and rehabilitation nursing is a plus.
    • Experience: Mitchell’s Nurse Reviewers are Registered Nurses and will typically have at least 3 years clinical experience and one year within utilization review.
    • Written Abilities:  Proficient grammar, sentence structure and written communication skills required.
    • Licenses or Certifications: You must be a registered nurse (RN). Having certifications within Legal Nurse Consulting and CPC are a plus.

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

    Mitchell International, an equal opportunity employer, values the diversity of our workforce and the knowledge of our people.  Mitchell will not discriminate against an applicant or employee on the basis of race, color, religion, national origin, ancestry, sex/gender, age, physical or mental disability, military or veteran status, genetic information, sexual orientation, gender identity, gender expression, marital status, or any other characteristic protected by applicable federal, state or local law.

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