Rising Medical Solutions · 16 hours ago
Utilization Review Specialist
United States
Full-time
Remote
New Grad, Entry LevelRising Medical Solutions is seeking a Utilization Review Specialist to join their team. The role involves bridging between a Utilization Review Nurse and Pre-Clinical Coordinator, performing various tasks related to utilization review such as monitoring referrals, evaluating medical records, and providing determinations based on evidence-based guidelines.
Health CareMedical
Responsibilities
Initiate and maintain appropriate verbal and/or written contacts with employers, clients, claimants, and medical providers
Set up files in all appropriate systems; assign files, when applicable, to the nurse
Facilitate and schedule appointments as needed, and keep the Telephonic Nurse Case Manager (TCM), clients, claimants, providers, and employers informed verbally and/or in writing of any changes, delays, updates, or problems
Maintain appropriate electronic and paper files
Obtain authorization for medical release of information from the adjuster, as necessary, for records acquisition
Interface with a variety of inter-disciplinary providers (e.g., PT, diagnostic, psychology, etc.)
Identify, maintain, and update participating providers
Answer incoming calls and direct the call appropriately. Responds to various written and telephonic inquiries regarding status of case
Screen all re-open files (subsequent URs) to determine duplicate requests, vs. an appeal request that is beyond the allotted timeframe, vs. a reconsideration, vs. a new UR
Basic invoicing at completion of UR process
Review medical records for completion and request additional records as needed to process the UR request
Using approved evidence-based guidelines to determine if treatment request is medically necessary. If guidelines are not met, process request for Peer or Physician Review
Write nurse summaries on all UR files
Document properly in Rising's database (and client databases when appropriate), and send determination letters on each completed UR
Track the ongoing status of all UR activity so that appropriate turn-around times are met
Maintain organized files containing clinical documentation of interactions with all parties of every claim
Utilize good clinical judgment, careful listening, and critical thinking and assessment skills
Qualification
Required
Initiate and maintain appropriate verbal and/or written contacts with employers, clients, claimants, and medical providers
Set up files in all appropriate systems; assign files, when applicable, to the nurse
Facilitate and schedule appointments as needed, and keep the Telephonic Nurse Case Manager (TCM), clients, claimants, providers, and employers informed verbally and/or in writing of any changes, delays, updates, or problems
Maintain appropriate electronic and paper files
Obtain authorization for medical release of information from the adjuster, as necessary, for records acquisition
Interface with a variety of inter-disciplinary providers (e.g., PT, diagnostic, psychology, etc.)
Identify, maintain, and update participating providers
Answer incoming calls and direct the call appropriately. Responds to various written and telephonic inquiries regarding status of case
Screen all re-open files (subsequent URs) to determine duplicate requests, vs. an appeal request that is beyond the allotted timeframe, vs. a reconsideration, vs. a new UR
Basic invoicing at completion of UR process
Review medical records for completion and request additional records as needed to process the UR request
Using approved evidence-based guidelines to determine if treatment request is medically necessary. If guidelines are not met, process request for Peer or Physician Review
Write nurse summaries on all UR files
Document properly in Rising's database (and client databases when appropriate), and send determination letters on each completed UR
Track the ongoing status of all UR activity so that appropriate turn-around times are met
Maintain organized files containing clinical documentation of interactions with all parties of every claim
Utilize good clinical judgment, careful listening, and critical thinking and assessment skills
Company
Rising Medical Solutions
Rising Medical Solutions is a innovative medical cost containment,care management & financial management companies.
Founded in 1999
51-200 employees
Funding
Current Stage
Growth StageLeadership Team
Jason Beans
CEO/President
John Paolacci
Chief Operating Officer
Recent News
2025-10-09
2025-09-12
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