UM Reviewer I, United States (Remote)

Job Description

The UM Reviewer I applies professional clinical knowledge to review medical information to determine if requested treatment is medically necessary and appropriate to support the resolution of the claim.

Responsibilities

• Uses clinical RN or RPT training and knowledge to render authorization decisions of medical necessity of requested medical treatment
• Analyzes medical information and applies clinical knowledge and established criterion to facilitate the utilization review process
• Researches, reviews and prepares medical information to present and collaborate objectively with Broadspire Peer Physicians in order to facilitate case resolution
• Communicates with physician providers and physician peer reviewers, nurse case managers, claim examiners, attorneys, clients as necessary to clarify clinical/claim issues to facilitate the UR process
• Independently makes decisions related to the management of each UR request based on clinical expertise, State/URAC/ Client requirements
• Plans and organizes individual caseload to meet URAC and Jurisdictional regulatory requirements for timelines, notifications and documents
• Utilized appropriate desktop resources to perform the utilization review process
• Collaborates and communicates effectively to promote the integration of all Broadspire Departments and products through interdepartmental referrals and communications
• Documents pertinent information in internal and external communications to support Utilization Management determinations and case resolution
• Ability to be flexible to meet department expectations and/or business needs.
• Perform other duties as assigned
• Upholds the Crawford Code of Business Conduct at all times
• Plans and organizes individual caseload to meet Massachusetts regulatory requirements for timelines, notifications and documents

Qualifications

• Bachelor of Science in Nursing or related clinical degree preferred. Must hold an RN or RPT License.
• Minimum of three (3) years diverse clinical experience or prior experience in managed care/workers compensation.
• Possess clinical training and knowledge consistent with RN or RPT licensure
• Ability to make independent clinical decisions within the scope of RN/RPT licensure.
• Ability to work in an unstructured environment with staff located remotely throughout the country.
• Must have strong written and verbal communication skills, as well as the ability to work well within a team environment.
• Must have strong organizational skills.
• Working knowledge of personal computers with the ability to use standard word processing software applications.
• Must possess a current, professional Registered Nurse or Registered Physical Therapy License to practice as a health professional in a state or territory of the United States with a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review.
• Current RN home state licensure in good standing without restrictions with the State Board of Nursing.

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About Us

Why Crawford? Because a claim is more than a number — it’s a person, a child, a friend. It’s anyone who looks to Crawford on their worst days. And by helping to restore their lives, we are helping to restore our community – one claim at a time. At Crawford, employees are empowered to grow, emboldened to act and inspired to innovate. Our industry-leading team pioneers new solutions for the industries and customers we serve. We’re looking for the next generation of leaders to take this journey with us. We hail from more than 70 countries and speak dozens of languages, reflecting the global fabric of the audience we serve. Though our reach is vast, we proudly operate as One Crawford: united in purpose, vision and values. Learn more at www.crawco.com. When you accept a job with Crawford, you become a part of the One Crawford family. Our total compensation plans provide each of our employees with far more than just a great salary

• Pay and incentive plans that recognize performance excellence
• Benefit programs that empower financial, physical, and mental wellness
• Training programs that promote continuous learning and career progression while enhancing job performance
• Sustainability programs that give back to the communities in which we live and work
• A culture of respect, collaboration, entrepreneurial spirit and inclusion

Crawford & Company participates in E-Verify and is an Equal Opportunity Employer. M/F/D/V Crawford & Company is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at Crawford via-email, the Internet or in any form and/or method without a valid written Statement of Work in place for this position from Crawford HR/Recruitment will be deemed the sole property of Crawford. No fee will be paid in the event the candidate is hired by Crawford as a result of the referral or through other means. Apply Now Job Info

• Job Identification3289
• Job CategoryUSA Medical Case Mgrs/UR Nurses
• Posting Date15/11/2025, 02:09
• Job ScheduleFull time
• Locations 5335 Triangle Parkway NW, Peachtree Corners, GA, 30092, US(Remote)

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