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 recognized 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 appropriate 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 regard 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.Previously Utilization Review experience Required. Minimum 2 years of clinical or related field experience in acute care, emergency medicine, medical surgery, orthopedic practice or other medical environment where experience could be applied to occupational 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.Comp: 75-85K#LI-NM2