Utilization Reviewer

At Enlyte, we combine innovative technology, clinical expertise, and human compassion to help people recover after workplace injuries or auto accidents. We support their journey back to health and wellness through our industry-leading solutions and services. Whether you're supporting a Fortune 500 client or a local business, developing cutting-edge technology, or providing clinical services you'll work alongside dedicated professionals who share your commitment to excellence and make a meaningful impact. Join us in fueling our mission to protect dreams and restore lives, while building your career in an environment that values collaboration, innovation, and personal growth.

Be part of a team that makes a real difference.

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 treatmentplans, 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.

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