Utilization Reviewer

Company Overview

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.

Job Description

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.
  
  
  

Qualifications

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.
  
  
  

Benefits

We’re committed to supporting your ultimate well-being through our total compensation package offerings that support your health, wealth and self. These offerings include Medical, Dental, Vision, Health Savings Accounts / Flexible Spending Accounts, Life and AD&D Insurance, 401(k), Tuition Reimbursement, and an array of resources that encourage a lifetime of healthier living. Benefits eligibility may differ depending on full-time or part-time status. Compensation depends on the applicable US geographic market. The expected base pay for this position ranges from $52,719 - $76,000 annually, and will be based on a number of additional factors including skills, experience, and education.

The Company is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability.

Don’t meet every single requirement? Studies have shown that women and underrepresented minorities are less likely to apply to jobs unless they meet every single qualification. We are dedicated to building a diverse, inclusive, and authentic workplace, so if you’re excited about this role but your past experience doesn’t align perfectly with every qualification in the job description, we encourage you to apply anyway. You may be just the right candidate for this or other roles.

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