Health Care Professional (HCP)—Utilization Review - Remote
UR is a collaborative process to promote quality cost effective outcomes, which enhance the physical, psychosocial, and vocational health of individuals. The process follows mandates per the SB863 and the California Labor Code. The HCP applies and provides technical knowledge and experience to the field of utilization management to assess the medical necessity of provider requests for services. ACOEM and MTUS are evidence-based guidelines, which have been presumed correct per California statutes, and is to be referenced for decisions. Official Disability Guidelines (ODG) are also evidence based guidelines, and is to be referenced for decisions.
Specifics: Full Time, Monday - Friday 8am - 5pm or 8:30am - 5:30pm (must be able to work PST hours), working remotely from home
The job responsibilities include:
- Perform a complete evaluation of the medical data for the request
- Collect additional relevant data as needed to make a decision on medical necessity
- Analyze the collected data to determine medical necessity as per evidence-based guidelines
- Discuss the analyzed data and the comprehensive plan of care with the insurance representative prior to implementation as needed
- Upon authorization, provide notification of decision to provider, requester, claimant, carrier, and all other parties as mandated by law
- Coordinates information between all parties (injured worker, physicians, employer, other providers, such as therapists, and attorney, if any are involved)
- Participate in annual audits of work product to ensure compliance
- Professional interaction with EKHS staff, members of the medical community, and all customers of EKHS; both in oral and written forms
- All work is done within the scope of practice of an RN, DC, PT, LVN, or LAc in California
- Participate in teleconferences and staff meetings as scheduled
- Other duties as assigned
- Graduate of an accredited school of nursing, chiropractic, or other related medical program (RN, DC, PT, LVN, LAc)
- Valid license in the appropriate scope of practice in good standing with no restrictions
- Possesses and can demonstrate the professional and technical skills required
- Experience in UR, Workers’ Compensation experience highly preferred, but not required
- 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
- Ability to lift up to 20 lbs
- Sit (approx. 75-100% of the time), stand (approx. 0-40% of the time), type (approx. 75-100% of the time) and do the job with or without reasonable accommodation.
EK Health Services has built a reputation for offering superior, goal-oriented Workers’ Compensation case management, utilization review, and bill review services. Our emphasis on medical excellence, superior service, impartial reporting, and case resolution is the driving force behind our consistent annual growth. We are excited about expanding our footprint across the United States as we continue to seek opportunities to Transform Managed Care.
Employees are provided with competitive compensation and benefits, including but not limited to medical, dental, vision, PTO, and 401k. Please visit our website for more information at www.ekhealth.com.