- Professional
- Office in Orlando
Our Story
Imagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.
Davies is looking for a Utilization Review Specialist that is responsible for conducting precertification reviews in accordance with URAC guidelines and accepted medical criteria. This role ensures the prompt coordination of appropriate care for approved procedures, verifies medical necessity and causal relation to reported workplace accidents, and confirms that requests originate from authorized treating physicians. The Specialist will coordinate Peer Reviews, facilitate Peer-to-Peer Telephonic Reviews, and manage processes for Precertification, Concurrent Reviews, Appeals, and Retrospective Peer Reviews, while ensuring compliance with all state-mandated Utilization Review timeframes.
Key Responsibilities
- Complete precertification of medical requests assigned by manager or coordinator.
- Refer cases not meeting accepted criteria to a Peer Review physician.
- Formulate and present appropriate questions to Peer Physicians, including adjuster and telephonic case manager concerns.
- Prepare final reports upon receipt of Peer Physician recommendations and distribute to appropriate parties.
- Draft and finalize required documentation and correspondence per established protocols.
- Ensure compliance with URAC criteria, AmeriSys standards, and all internal policies and procedures.
- Document all interview, contact, and medical record data accurately in the electronic system.
- Create, edit, and revise correspondence as required.
- Maintain patient confidentiality in compliance with HIPAA, state, and federal regulations.
- Advocate for patients while upholding legal, ethical, and accreditation standards.
- Participate in organizational committees such as Grievance and Quality Assurance as assigned.
- Negotiate fees with providers or direct cases to other vendors as appropriate.
- Perform additional duties as assigned.
Skills, knowledge & expertise
- Strong knowledge of Workers’ Compensation laws and their application within managed care arrangements and AmeriSys standards.
- Active membership in a Utilization Review professional organization preferred.
- Up-to-date knowledge of medical trends, standards, and regulatory changes.
- Self-directed with the ability to work independently and efficiently.
- Proficient in personal computers, claims systems, and business software applications.
- Strong communication skills, both oral and written.
- Demonstrates reliability, professionalism, teamwork, and customer service excellence.
- Registered Nurse (RN) with at least three (3) years of clinical experience in hospital specialty units (ER, ICU/CCU, Surgery, Trauma, Orthopedic, Neurology, or Psychiatry).
- Minimum of two (2) years of Utilization Review experience in Workers’ Compensation, Health & Accident, or Auto Liability preferred.
- Certification in Utilization Review (CPUR, ABQUARP) strongly preferred.
- Current State or Multi-State RN licensure required.
Benefits
Benefits
At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes:
- Medical, dental, and vision plans to ensure your health and that of your family.
- A 401k plan with employer matching to help you build a secure financial future.
- Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
- Paid holidays.
- Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.
Diversity and Inclusion
Davies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard.
