Utilization Review Specialist

Pinnacol Assurance does just one thing, and does it better than anyone: provide caring workers’ compensation protection to Colorado employers and employees. And while we may be a little biased, we believe that our work shapes communities and changes lives.

We have big hearts and love big ideas. We’ve been around for more than  100 years, but don’t let that fool you. Pinnacol is committed to taking care of Colorado employers and workers in the most innovative ways. We celebrate continuous improvement, new ideas, compassion, teamwork, integrity and excellence.

With our number one priority to keep everyone safe, along with the heart of Pinnacol’s “culture of caring” to do what is right and not what is easy, we’re currently having our team members work from home. But we’re still making time for fun with virtual events like virtual painting classes, virtual yoga and Zumba classes, and virtual happy hours!

What you’ll do:

Responsible for helping to establish a new utilization review (UR) department within Pinnacol. Key areas of focus include carrying out reviews of medical records and prior authorization requests to determine the clinical necessity and appropriateness of medical services that have been requested or previously furnished. To inform these reviews, follows standardized protocols informed by evidence-based guidelines and similar literature. Communicates with community medical providers to request information and provide education. Shares pertinent information with independent physician advisors who make final payment (coverage) determinations. Communicates with injured workers about coverage decisions. Collaborates with bill pay processors to ensure that approved and denied services are paid appropriately. Collaborates as needed with medical nurse case managers, claims adjustors, and other internal and external stakeholders.  Supports and participates in a transition towards increasing UR efficiency and automation by taking advantage of new software that streamlines workflows and helps manage information and communication.

What you can expect:

• Conducts timely preauthorization and retrospective utilization reviews and manages appeals.
• Develops expertise in clinical appropriateness criteria for specific kinds of medical services.
• Organizes and communicates information necessary to complete reviews.
• Communicates with injured workers about coverage decisions.
• Communicates necessary information with billing to ensure payment appropriateness.
• Maintains current and accurate documentation in Salesforce, Excel, WCIS, and Medata systems.
• Accurately documents all review determinations and contacts providers and members according to established time frames.
• Identifies and refers cases that do not meet established clinical criteria to the utilization review management team.
• Collaborates with Claims, Quality Management, Nurse Case Management, and Provider Relations as requested.
• Good interpersonal skills, able convey disappointing information tactfully and empathically.
• Ability to multi-task and work efficiently in a busy environment; flexibility to alternate between on- site and remote work.
• Highly organized; excellent documentation skills; strong ability to keep track of tasks and meet deadlines; detail-oriented; attentive to ensuring data integrity and informational accuracy.
• Proactive about identifying and solving problems; timely and resourceful in relation to soliciting
• Has a curious mindset; an openness to learning about and developing expertise in new software packages and applications.
• Has a reasonable level of comfort with organizational change and sustained attention to continuous

Additional Duties:

• Manage conflicting priorities involving multiple utilization review projects and cross functional team members
• Support Pinnacol’s culture by striving for excellence in all aspects of the job with a focus on positive interpersonal relationships with co-workers
• Ability to build credibility and establish trust within the medical community and all levels of Pinnacol
• Perform other duties as assigned

What you need to be successful:

• High school or equivalent; 4 year college degree (preferred).
• Minimum of 1 year of experience in a position involving analytic evaluations of written information.
• Experience in a health care setting that involved gaining familiarity with health care operations and billing (preferred).
• Ability to come into the office at least 3-4 times per week

• Our benefits go beyond the basics. You’ll get to choose from diverse benefit offerings for medical, dental and vision.
• We care about each other. We enjoy a positive, collaborative work environment. We are hard workers and high performers.
• We love who you are. Pinnacol is on a journey to embody diversity, equity and inclusion. We’re committed to creating a culture that deeply values differences, where everyone feels like they belong.
• Take a day (or 20!) off. Enjoy 20 paid days off your first full year plus 9 paid holidays.
• Take care of yourself. Sign up for unique wellness programs, including on-site, company-paid fitness facilities and classes
• Get your learning on. We promote a learning culture to help you master your current job and cultivate the skills of the future through a variety of on-site, online, and off-site professional development opportunities.
• Give back and get paid. Through our employee volunteer program, Pinnacol in Action, employees receive paid time off to volunteer with Colorado nonprofits.
• Share in our success. You’ll have the opportunity to earn a quarterly incentive, up to 20 percent of your annual base salary, when your team exceeds their goals and objectives.

When we find the right person, we try to put our best foot forward with an offer that excites you. We consider what you’d like to be paid, the skills and experience you bring, what similar jobs pay in the Denver area and make sure there’s equal pay for equal work among those you’ll be working with. The compensation amount for this role is targeted at $22.64-$24.47/hr. Final offer amounts are determined by multiple factors including your experience and expertise and may vary from the amounts listed above.

Want to love your work? Apply today!

Pinnacol is committed to working with and providing reasonable accommodations to applicants with disabilities. To request assistance with the application process, please email [email protected].