Encompass Workers' Comp Solutions is seeking a California-licensed healthcare professional to join our Utilization Review team as a Health Care Professional (HCP) / First-Level Reviewer.
This position may be filled by a Licensed Vocational Nurse (LVN), Registered Nurse (RN), or Doctor of Chiropractic (DC) with an active, unrestricted California license.
The Health Care Professional performs first-level utilization review of treatment authorization requests for injured workers. The HCP reviews clinical documentation and applies California's Medical Treatment Utilization Schedule (MTUS) and other applicable evidence-based guidelines to determine whether requested treatment meets criteria for authorization.
The HCP may approve treatment requests when applicable criteria are satisfied. Requests that cannot be approved at first-level review are prepared and referred to the appropriate Physician Reviewer.
The HCP does not modify or deny Requests for Authorization. All modification and denial decisions are made by Physician Reviewers.
What You'll Do
- Review Requests for Authorization and supporting medical documentation for completeness.
- Apply MTUS and other applicable evidence-based clinical guidelines.
- Determine whether sufficient clinical information is available to complete the review and request additional information when necessary.
- Make first-level review determinations within applicable regulatory timeframes.
- Approve treatment requests when applicable criteria are satisfied.
- Communicate professionally with requesting providers to obtain additional information and discuss treatment requests as appropriate.
- Prepare and refer cases that cannot be approved at first-level review to the appropriate Physician Reviewer.
- Review additional medical information received in connection with reconsiderations.
- Identify and appropriately process duplicate Requests for Authorization.
- Maintain accurate and timely documentation of utilization review activity.
- Ensure required communications and regulatory timeframes are met.
- Manage multiple reviews, priorities, and deadlines in a fast-paced remote work environment.
Required Qualifications
- Active, unrestricted California professional license as an LVN, RN, or DC.
- Must reside and work in California.
- Clinical experience relevant to your licensed discipline and the clinical services being reviewed. Three or more years of relevant clinical experience is preferred.
- Strong clinical assessment, critical-thinking, analytical, and problem-solving skills.
- Excellent written and verbal communication skills.
- Strong attention to detail, organization, and time-management skills.
- Ability to work independently and manage multiple priorities and deadlines.
- Ability to navigate multiple software systems concurrently.
- Proficiency with Microsoft Office and web-based platforms.
- Minimum typing speed of 45 WPM.
- Ability to perform extensive telephone- and computer-based work.
Preferred Qualifications
- Previous workers' compensation experience.
- Previous utilization review or utilization management experience.
- Experience in occupational medicine, orthopedics, neurology, rehabilitation, musculoskeletal care, acute care, case management, occupational health, disability management, or another relevant clinical specialty.
- Familiarity with MTUS and evidence-based treatment guidelines.
- Relevant professional certification or advanced credential appropriate to your discipline.
Schedule & Work Environment
- Full-time
- Monday-Friday during standard business hours
- Home-based/remote position
- Must work from within California
- Hourly, non-exempt
- Overtime eligible in accordance with applicable California law
Compensation
$42.00-$45.00 per hour
The compensation range reflects the responsibilities and requirements of the Health Care Professional/First-Level Reviewer position. Actual starting compensation within the range will be based on relevant utilization review and workers' compensation experience, clinical experience, qualifications, certifications, and other job-related factors.
This is an opportunity to use your clinical experience in a different way-helping facilitate timely, medically appropriate treatment decisions for injured workers while working in a structured, professional, home-based environment.
At Encompass, we value clinical integrity, accuracy, professionalism, and doing the right thing for our clients, providers, injured workers, and employees.
