April 29, 2026 - Posted on WorkCompWire Leaders Speak (Part One)
By Hagan Joiner, Executive Director, PeerLink Medical
Utilization Review (UR) is one of the most critical and misunderstood functions in workers’ compensation. At its simplest, UR exists to answer a single question:
Is the requested care medically necessary and appropriate for the injured worker?
Behind that simple question, however, sits a highly structured system shaped by regulation, accreditation standards, and layered clinical decision-making. Understanding how these elements fit together is essential for organizations responsible for delivering compliant, defensible UR outcomes.
At a foundational level, every effective UR program relies on four core components.
1. A Clear Clinical Purpose
At its core, UR serves a clinical and operational purpose: to ensure injured workers receive care that is supported by evidence-based guidelines and aligned with medical necessity standards.
While UR decisions are frequently scrutinized by regulators, providers, and legal stakeholders, the function itself is not intended to be punitive. It is designed to support appropriate care delivery while maintaining consistency, fairness, and defensibility across claims.
This purpose remains consistent regardless of jurisdiction, payer, or review volume. What changes is how programs are structured to support it.
2. A State-Driven Regulatory Framework
Workers’ compensation is governed at the state level, and UR requirements reflect that decentralization.
According to a 2024 study published by WCRI1, roughly 20 states require UR programs and define strict timelines, documentation requirements, and escalation protocols. Others enforce UR indirectly through medical treatment guidelines, certification requirements, or payer-driven expectations.
The result is a system where:
For organizations managing claims across multiple states, this creates a central challenge:
UR programs must be standardized enough to operate efficiently while remaining flexible enough to meet state-specific expectations.
3. Accreditation as the Unifying Standard
As regulatory complexity has increased, so has the need for external validation of UR processes. This is where URAC accreditation plays a critical role.
URAC establishes nationally recognized standards for utilization management, including workers’ compensation UR programs. While not required in every state, URAC accreditation is widely viewed as a gold standard and is often preferred—or effectively required—by payers and regulators.
Importantly, URAC provides a unifying framework across jurisdictions by establishing consistent expectations in five key areas:
For multi-state organizations, accreditation serves two essential functions:
In an environment where UR determinations are frequently scrutinized, accreditation strengthens confidence that decisions are fair, defensible, and aligned with nationally recognized standards.
4. A Layered Clinical Review Model
While regulations and accreditation define how UR should operate, the clinical review process itself is intentionally layered. Not every request requires the same level of review or clinical intervention.
Front-End Screening and Nurse-Level Review
Most UR programs begin with an initial comparison of the requested treatment against evidence-based medical guidelines. Increasingly, this front-end review is supported by clinical decision support tools that help standardize and accelerate the process.
This approach allows organizations to:
When a request doesn’t align with established guidelines and documentation is insufficient, it is typically reviewed by a registered nurse. Nurse reviewers focus on:
For straightforward cases, nurse-level review provides both efficiency and consistency, allowing routine requests to be resolved quickly.
Physician Advisor Review
When a request falls outside of established guidelines, lacks sufficient documentation, or raises medical necessity concerns, it is escalated to a physician advisor.
This level of review introduces clinical judgment where standardized criteria are no longer sufficient.
Physician advisors are responsible for:
In most jurisdictions, and under URAC standards, physician involvement is required for adverse determinations, such as denials or modifications of care. This makes physician advisor review a critical safeguard within the UR process.
Balancing Efficiency and Clinical Rigor
Together, nurse-level and physician-level reviews form a complementary system:
This layered model allows organizations to balance operational efficiency with clinical rigor, but it also introduces complexity. Clear escalation protocols, properly credentialed reviewers, and comprehensive documentation are essential at every level.
These operational realities are where regulatory requirements, accreditation standards, and day-to-day UR intersect most visibly.
Looking Ahead
As workers’ compensation continues to evolve, expectations around UR are increasing. Stakeholders are demanding greater transparency, stronger clinical justification, and faster turnaround times—without sacrificing quality or compliance.
Meeting these expectations requires more than adherence to rules. It requires a clear understanding of how UR functions at every level.
Next week, we’ll explore how leading organizations are addressing one of the most pressing challenges within this model today: ensuring access to the right physician expertise across specialties and jurisdictions without creating unsustainable operational burden.
About Hagan Joiner, PeerLink Executive Director
As the Executive Director at PeerLink Medical, Hagan has spent the past decade leading operational growth and delivering high-quality clinical review solutions within the workers’ compensation and disability space. With a strong background in team leadership and client engagement, Hagan has played a key role in driving performance, strengthening partnerships, and supporting scalable service delivery.
Prior to joining PeerLink Medical, Hagan held leadership roles in both telecommunications and banking and attended the University of Montevallo in Alabama.
About PeerLink
PeerLink Medical was founded in 2012 as a physician-led independent peer review organization providing medical review services to insurers and other payers. PeerLink became a part of Emperion in 2025. Emperion has offered Independent Medical Examination and Peer Review solutions, for the past 4 decades, from six regional service centers and more than thirty-five clinic-based settings. With a vast network of 25,000 providers spanning all medical specialties, they drive patient recovery, facilitate return to pre-injury status, and achieve successful outcomes in Workers’ Compensation, Automobile, Disability, and Health benefit systems.
Notes
1Workers’ Compensation Medical Cost Containment: A National Inventory, 2024. Karen Rothkin. February 2024. WC-24-16.