Clinical Utilization Review Specialist

Berkshire Hathaway Homestate Companies - Workers Compensation Division; Omaha (NE); On-site; USD 60,000 - 76,000; Full time

Job summary

Berkshire Hathaway Homestate Companies, Workers Compensation Division, in Omaha, is seeking a Utilization Review Specialist to join its Medical Management team. You will ensure medical treatment requests are appropriate and reviewed in line with state laws and company policies.

The role involves triaging requests, reviewing authorizations against guidelines, researching claim files, and communicating with providers, injured workers, and claims staff to support integrated medical management.

Qualifications

• Bachelor's or Associate's degree in a medical field required.
• Minimum 6 months of relevant experience or training in a medical field.
• Proficient in Microsoft Office/365 applications and able to become proficient in proprietary and vendor software.
• Able to read and understand medical documents and write clear, concise reports.

Responsibilities

• Triages and manages intake coordination of requests for authorization and independent medical review requests.
• Reviews authorization requests for approval in accordance with evidence-based medical treatment guidelines.
• Researches claim files, interprets medical reports, and applies guidelines to requested treatment.
• Advocates for the injured worker and Claims department and ensures requests are appropriate for the diagnosis.
• Escalates requests outside authorization authority for review by senior UR staff.
• Ensures UR processes meet state law and company policy time limits.
• Contacts providers to clarify requests and obtain additional medical information as needed.
• Maintains thorough understanding of company policies on authorization review.
• Collaborates with Medical Bill Review and other staff for integrated management of treatment.
• Maintains patient confidentiality and safeguards protected health information.
• Provides general office or administrative support.

Skills

Medical background

Microsoft Office

Communication

Regulatory knowledge

Documentation

Education

Bachelor's or Associate's degree in a medical field

Tools

Microsoft Office/365

Proprietary software

Job description

Berkshire Hathaway Homestate Companies, Workers Compensation Division, in Omaha, is seeking a Utilization Review Specialist to join its Medical Management team. You will ensure medical treatment requests are appropriate and reviewed in line with state laws and company policies.

The role involves triaging requests, reviewing authorizations against guidelines, researching claim files, and communicating with providers, injured workers, and claims staff to support integrated medical management.