Description and RequirementsGeneral Description: Determine the quality of care provided to injured employees for Third Party Administration (TPA) accounts including whether the medial service/procedure is appropriate and effective. Review appropriateness of the health care service to ensure that is medically necessary and reasonable based on objective, clinical findings.
Responsibilities: - Review complex workers compensation medical treatment requests to ensure accordance with evidence based medical treatment guidelines, which are generally recongnized by the national medical community and are scientifically based.
- Research claim file in relation to the requested medical treatment while interpreting medical reports/claim summaries and applies appropriate established guidelines to requested treatment. Refer treatment requests which do not meet guidelines, for peer review and determination.
- Advocate for the injured worker and claims department, ensuring proposed treatment requests are appropriate for the diagnosis
- Perform daily tasks within the apporpriate established workflow processes, utilize accepted guidelines, and meets legislative and departmental timeframes.
- Maintain patient confidentiality in discussions of treatment/disease process and conditions.
- Routinely contact providers to clarify treatment requests, examination findings as well as obtain additional medical information as needed.
- Maintain clear, concise, and accurate documentation of requested medical treatments to include clinical findings, treatment guidelines and determinations.
- Act as a medical resource in regards to utilization review to claims support nurse and claims department.
- Foster a positive and close working relationship with company staff, including claims staff, medical bill review, case manager, legal and client services.
- Communicate effectively with individuals outside the company, including clients, medical providers, and vendors.
Personal and Organizational Skills: - Superior written and oral communication skills.
- Ability to work well in a team environment.
- Must have strong analytical thinking and problem-solving skills.
- Strong organizational skills required.
Knowledge, Skills and Abilities: - Registered Nurse (RN) from accredited college; bachelors' degree preferred. Must have an active state license and is eligible to obtain additional state licenses.
- Minimum 2 years of clinical or related field experience in acute care, emergency medicine, medical surgery, orthopedic practice or other medical enviroment where experience could be applied to occcupational health.
- Knowledge of managed care industry practices, including medical case management, utilization review and related legal, regulatory and evidence based medical treatment guidelines.
- Strong clinical background in orthopedics, neurology or rehabilitation.
- Highly organized, with ability to manage work involving large client volume and adherence to regulatory time frames.
- Strong understanding of managed care technology applications.
- Excellent communication skills, both verbal and written.
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USI is committed to providing a full-suite of competitive benefits for our growing population and its diverse needs. We offer a wide range of health, welfare and financial benefits including medical, wellness, dental and vision, 401(k), flexible spending and health savings accounts, short and long-term disability, life insurance and other unique employer-sponsored and voluntary programs. USI also offers a generous paid time off policy, paid family leave benefit as well as paid holiday time.
$75k-$100k
