TPA Utilization Nurse

2 weeks ago

Needham Heights MA United States USI Insurance Services Full time
Job DescriptionGeneral 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

Why USI?

With more than $2.5 billion in revenue and over 10,000 associates across 200+ offices nationwide, USI is one of the largest insurance brokerage and consulting firms in the world. At USI, we have created one of the most dynamic personal and professional development cultures in the industry. We invest heavily in our associates, and we take pride in celebrating their growth and success through our one-of-a-kind employee reward and recognition programs. We invite you to learn more about what makes USI an exceptional place to work

Unrivaled Resources and Support

What truly distinguishes USI as a premier insurance brokerage and consulting firm is the USI ONE Advantage® , a game-changing value proposition that delivers to clients a robust set of risk management and benefit solutions with bottom-line financial impact. USI ONE® represents Omni, Network, Enterprise—the three key elements that set USI apart from the competition. Through USI ONE, we develop strategic, timely and effective risk management and benefit programs in terms that are easy to understand, and we demonstrate how the solutions can have a positive economic impact.

Industry-Leading Programs, Rewards, and Recognition

In addition to competitive pay, incentives, and benefits, USI recognizes associates through our Summit Awards program, rewarding excellence in those who build our brand each day. USI offers employee programs that recognize outstanding achievement and help our associates lead healthy, productive lives. We turn care into action with our award-winning wellness program, college scholarships for associates' children, and financial help in times of need.

Deep Community Engagement

We are committed to giving back to our local communities and supporting a culture of environmental sustainability. From sharing our time, talent, and resources to support local non-profit organizations, animal shelters, and environmental beautification and restoration projects – to partnering with eco-conscious vendors and taking steps to reduce our own environmental footprint – we’re working together as ONE to build a better future.

Committed to a Diverse, Equitable, and Inclusive Workplace

Our award-winning I’m With U diversity, equity, and inclusion program educated our associates to help them better understand and serve our clients, prospects, fellow team members, and local communities through curated education and training resources, employee support programs, and community outreach initiatives to build a more diverse, equitable, and inclusive culture.

Nationally Recognized as a Top Insurance Employer

  • Recognized as one of Insurance Business America’s Top Insurance Employers for six consecutive years (2018-2023).
  • Named to Business Insurance’s annual list of the Best Places to Work in Insurance four years in a row (2020-2023).
  • Recipient of the American Heart Association’s Gold Status for a maintaining a culture of health and well-being five years in a row (2018-2022).
  • Visit our Awards and Accolades page for a complete list of industry awards and recognitions

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 .

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