Utilization Reviewer

The Enlyte Family of Businesses

Mitchell | Genex | Coventry

Enlyte is the parent brand of Mitchell, Genex and Coventry, an organization unlike any other in the Property & Casualty industry, bringing together three great businesses with a shared vision of using technology innovation, clinical services and network solutions to help our customers and the people they serve. Our suite of products and services enable our employees to help people recover from challenging life events, while providing opportunities for meaningful impact and career growth.

We are seeking a qualified Utilization Reviewer who can work remotely from home. The ideal candidate performs utilization review on workers' compensation related prospective, concurrent, and retrospective treatment referrals. The ideal candidate will play a crucial role in assessing and ensuring the appropriateness of medical treatment plans, contributing to effective claims management and optimal patient outcomes.

• 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 on application of solid clinical judgment.
• Collaborates with healthcare providers, claims adjusters, and other stakeholders to gather relevant information for comprehensive assessments.
• Evaluates medical documentation to ensure compliance with industry standards and regulatory requirements.
• Communicates findings clearly and concisely through written reports and verbal discussions.
• Stays up-to-date on industry regulations, medical advancements, and best practices to enhance the quality of reviews.
• Participates in team meetings and contributes to the continuous improvement of utilization review processes.

Minimum Education: Associates degree.

Required Skills and Experience:

• Must have active Registered Nurse (RN) license in the state of PA.
• Minimum of 2 years of clinical experience; or an advanced degree without experience.
• Knowledge of medical terminology, treatment modalities, and healthcare guidelines.
• Analytical and critical thinking skills for effective decision-making.
• Strong communication and interpersonal skills to liaise with diverse stakeholders.
• Ability to work independently and collaboratively within a team environment.
• Detail-oriented with strong organizational skills to manage multiple cases efficiently.
• Familiarity with relevant software and tools used in healthcare.

Desired Skills and Experience:

• Prior review experience in healthcare, insurance, utilization management, quality assurance, or other applicable capacity.
• Prior experience in the workers' compensations field.

PI259515297