USI Holdings Corporation

TPA Utilization RN

USI Holdings Corporation • $75K — $100K *
Warwick, RI 02886In-Person
Healthcare
Less than 5 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Registered Nurse (RN) with active state license; bachelor's degree preferred.
  • Minimum 2 years of clinical experience in acute care or related medical fields.
  • Knowledge of managed care practices and medical treatment guidelines.
  • Strong clinical background in orthopedics, neurology, or rehabilitation.
  • Ability to manage high volumes of work and adhere to regulatory timelines.

Responsibilities

  • Review workers' compensation medical treatment requests for guideline compliance.
  • Research claim files and interpret medical reports to support treatment decisions.
  • Advocate for injured workers and the claims department in treatment appropriateness.
  • Perform daily tasks according to workflow processes and timeframes.
  • Maintain confidentiality in patient treatment discussions.
  • Contact medical providers for clarification of treatment requests and findings.
  • Document medical treatment requests accurately, including clinical findings.

Benefits

  • Positive and collaborative work environment with various departments.
  • Opportunity to act as a vital medical resource within the claims support team.
  • Exposure to a diverse range of cases in occupational health.
  • Engagement with clients and medical providers, enhancing communication skills.
Full Job Description
Description and Requirements

General 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.


#LI-NM2

$75k-$100k

About USI Holdings Corporation

USI is a leading insurance brokerage and consulting firm, delivering property and casualty, employee benefits, personal risk, program and retirement solutions throughout the United States. Headquartered in Valhalla, New York, USI has over 200 offices across the United States. USI combines industry-leading national capabilities delivered through longstanding, passionate and committed local service teams. USI stands for Understand, Service and Innovate. At USI, we work to Understand the specific needs of our clients, to provide an unparalleled local Service experience, and to Innovate with cutting-edge solutions so our clients can continue to invest and grow.
Learn more about USI Holdings Corporation
Size
4,800 employees
Industry
Finance & Insurance
Founded
1994
* Ladders Estimates

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