Utilization Review Nurse

Travelers • Buffalo, NY

1d

About The Position

This position is responsible for conducting in-house utilization review with emphasis on determining medical necessity for prospective, concurrent, retrospective and appeal treatment requests for workers compensation claims. Responsible for helping to ensure the appropriate treatment is directly related to the compensable injury and for adhering to multi-jurisdictional Utilization Review criteria.

Requirements

• Registered Nurse; Licensed Practical Nurse or Licensed Vocational Nurse.

Nice To Haves

• Working knowledge of medical causation and relatedness.
• Working knowledge of jurisdiction-specific medical guidelines.
• Prior clinical experience.
• Intermediate medical knowledge of the nature and extent of injuries, periods of disability, and treatment.
• Intermediate customer service: ability to build and maintain productive relationships with medical providers as well as internal claim handlers.
• Working knowledge of URAC standards.
• Intermediate planning & Organizing: ability to establish a plan/course of action and contingencies for self or others to meet current or future goals.
• Intermediate teamwork: ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result.
• Intermediate analytical thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making.
• Intermediate communication skills: Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology.
• Basic negotiation: ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise.
• Basic principles of investigation: follows a logical sequence of inquiry determine if the treatment request is related to the compensable injury and medically necessary per jurisdictional guidelines.
• Basic legal knowledge: understanding and application of state, federal and regulatory laws and statutes.
• Basic worker’s compensation technical ability to apply available resources and technology to manage treatment plans.
• Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state.

Responsibilities

• Interpret routine, complex or unique medical information.
• Evaluate medical treatment to determine whether it was/is reasonable, necessary and causally related based upon jurisdictional guidelines.
• Submit accurate billing documentation on all activities as outlined in established guidelines.
• Engage specialty resources, as needed, to reach final determination of medical necessity.
• Utilize internal Claim Platform Systems to manage all claim activities on a timely basis.
• Utilize Preferred Provider Network per jurisdictional guidelines.
• Research medical information to support the claim review process.
• Occasional contact with provider to ensure the injured employee is actively participating in a viable treatment plan.
• Keep claim professional apprised of medical treatment request status.
• In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated.
• Perform other duties as assigned.

Benefits

• Health Insurance: Employees and their eligible family members – including spouses, domestic partners, and children – are eligible for coverage from the first day of employment.
• Retirement: Travelers matches your 401(k) contributions dollar-for-dollar up to your first 5% of eligible pay, subject to an annual maximum. If you have student loan debt, you can enroll in the Paying it Forward Savings Program. When you make a payment toward your student loan, Travelers will make an annual contribution into your 401(k) account. You are also eligible for a Pension Plan that is 100% funded by Travelers.
• Paid Time Off: Start your career at Travelers with a minimum of 20 days Paid Time Off annually, plus nine paid company Holidays.
• Wellness Program: The Travelers wellness program is comprised of tools, discounts and resources that empower you to achieve your wellness goals and caregiving needs. In addition, our mental health program provides access to free professional counseling services, health coaching and other resources to support your daily life needs.
• Volunteer Encouragement: We have a deep commitment to the communities we serve and encourage our employees to get involved. Travelers has a Matching Gift and Volunteer Rewards program that enables you to give back to the charity of your choice.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed