Initial Clinical Reviewer

Medical Reviewer - CT08BE

We’re determined to make a difference and are proud to be an insurance company that goes well beyond coverages and policies. Working here means having every opportunity to achieve your goals – and to help others accomplish theirs, too. Join our team as we help shape the future.

The Clinical team is seeking an Initial Clinical Reviewer. In this position, the individual will perform Drug Review/ Utilization Review for Workers’ Compensation Claims. An Initial Clinical Reviewer (ICR) is responsible for evaluating treatment requests in accordance with jurisdictional regulations. An ICR utilizes jurisdictional treatment guidelines as well as standardized evidence-based criteria to ensure treatment that is requested is necessary and medically appropriate for the compensable injury. Clinical judgement and critical thinking is utilized to achieve optimum, cost-effective treatment while partnering with claim partners, vendors, and healthcare providers.

Key Responsibilities Include

Evaluate treatment or service requests for medical necessity and appropriateness using nursing judgment, treatment criteria guidelines and Physician Advisor/Peer Clinical Review referral process. Conduct first level prospective, concurrent, or retrospective review, employing standardized evidence-based review criteria and treatment parameters to authorize services. Identify cases where additional information is required to complete the review and/or identify potential medical necessity cases. Negotiate alternative treatment plans within treatment criteria guidelines.

• Determine medical necessity/appropriateness, relatedness of treatment requests according to regulatory and ethics requirements
• Comply with URAC Workers’ Compensation Utilization Management Standards and Policy and Procedures
• Comply with URAC Standards and Policy and Procedures
• Maintain injured worker privacy, confidentiality and safety, advocacy, adherence to ethical and legal standards
• Process determinations within required jurisdictional and URAC timeframes
• Accurate use of all correspondence within regulatory, URAC and Utilization Review Policy and Procedure requirements
• Demonstrate appropriate network utilization in accordance with regulatory requirements
• Oversight of any delegated tasks
• This position will also be cross trained in Utilization Review
  
  

Qualifications

• RN with current unrestricted state licensure required
• CCM, CRC, CDMS or similar certification preferred; a plus
• Bachelor’s or higher degree in a health-related field preferred
• 3 years clinical practice experience with orthopedic, neurological, rehabilitation, medical/surgical or occupational health preferred
• 2 years workers’ compensation utilization management or case management experience preferred
• Basic Computer proficiency (Microsoft Office Products including Word, Outlook, Excel, Power Point); which includes navigating multiple systems
• Ability to effectively communicate telephonically and in written form
• Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone, and typing on the computer
• Work requires the ability to perform close inspection of handwritten and computer-generated documents as well as a PC monitor
• Ability to synthesize large volumes of medical records & facilitate multi-point care coordination
• Must meet productivity & quality expectations
• Ability to organize and prioritize daily work independently and effectively
  
  

Additional Competencies

• Strategic thinking
• Customer focus
• Business knowledge
• Problem solving
• Collaboration – partnership
• Decision making skills
• Communication skills
  
  

Additional Information

• Candidate must reside in Connecticut. This role can have a Hybrid or Remote work schedule. Candidates who live near one of our office locations (Hartford, CT Home Office) will have the expectation of working in an office 3 days a week (Tuesday through Thursday). Candidates who do not live near an office will have a remote work schedule, with the expectation of coming into an office as business needs arise.
  
  

Compensation

The listed annualized base pay range is primarily based on analysis of similar positions in the external market. Actual base pay could vary and may be above or below the listed range based on factors including but not limited to performance, proficiency and demonstration of competencies required for the role. The base pay is just one component of The Hartford’s total compensation package for employees. Other rewards may include short-term or annual bonuses, long-term incentives, and on-the-spot recognition. The annualized base pay range for this role is:

$66,000 - $99,000

Equal Opportunity Employer/Sex/Race/Color/Veterans/Disability/Sexual Orientation/Gender Identity or Expression/Religion/Age

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