Utilization Review Specialist

Utilization Review Specialist

Department: Claims Administration & Adjusting

Employment Type: Permanent - Full Time

Location: Home United States

Reporting To: Karen Shaffer

Compensation: $65,000 - $75,000 / year

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.

The Utilization Review Specialist is responsible for performing utilization review services in compliance with URAC guidelines, applicable state regulations, and Davies Medical Management Standards. This role plays a critical part in ensuring appropriate, timely, and medically necessary care for injured workers while maintaining regulatory compliance and high‑quality clinical decision‑making.

You will conduct precertification, concurrent, retrospective, and appeal reviews; coordinate peer reviews; and serve as a patient advocate throughout the medical review process.

• Perform precertification reviews using accepted medical criteria in accordance with URAC standards and state‑mandated time frames
• Ensure medical requests are causally related to reported injuries and submitted by authorized treating providers
• Forward cases that do not meet established criteria to peer review physicians
• Prepare and pose appropriate clinical questions to peer review physicians, incorporating concerns from adjusters and/or telephonic case managers
• Coordinate and facilitate peer‑to‑peer telephonic reviews, precertification, concurrent reviews, appeals, and retrospective reviews
• Complete final determinations and reports upon receipt of peer physician recommendations and communicate outcomes to all appropriate parties
• Accurately document all medical, clinical, and contact information in the computerized case management system
• Draft, edit, and revise correspondence and determination letters in accordance with established protocols
• Ensure compliance with URAC criteria and internal policies and procedures
• Maintain strict confidentiality of all patient, provider, and case‑related information in compliance with state and federal regulations
• Serve as a patient advocate while adhering to all legal, ethical, and regulatory standards
• Participate in committees such as Quality Assurance, Grievance, or other committees as assigned
• Negotiate fees with providers or refer cases to alternate vendors when appropriate
• Perform other duties as assigned

• Registered Nurse (RN) or Licensed Practical Nurse (LPN) with a minimum of three (3) years of clinical experience across varied hospital specialty units, including but not limited to ER, ICU/CCU, Surgery, Trauma, Orthopedics, Neurology, and/or Psychiatry
• Minimum of two (2) years of Utilization Review experience in Workers’ Compensation, Health & Accident, or Auto Liability (preferred)
• Proof of current, unrestricted state RN or LPN licensure or multi‑state compact licensure
• Strong working knowledge of Workers’ Compensation laws and managed care arrangements
• Ability to work independently with minimal supervision in a fast‑paced environment
• Proficiency with computers, utilization review systems, and standard business software
• Excellent written and verbal communication skills
• Strong organizational, documentation, and time‑management skills
• Collaborative team player with strong customer service orientation
• Commitment to maintaining current knowledge of industry trends, regulations, and standards

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,…