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Utilization Review Nurse

1 month ago

Buffalo, New York, United States Travelers Insurance Full time
Job Summary

Travelers Insurance is seeking a skilled Utilization Review Nurse to join our team. As a Utilization Review Nurse, you will be 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.

Key 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.

Requirements:

  • Registered Nurse; Licensed Practical Nurse or Licensed Vocational Nurse required.
  • Working knowledge of medical causation and relatedness preferred.
  • Working knowledge of jurisdiction-specific medical guidelines preferred.
  • Prior clinical experience preferred.
  • Intermediate medical knowledge of the nature and extent of injuries, periods of disability, and treatment preferred.
  • Intermediate customer service: ability to build and maintain productive relationships with medical providers as well as internal claim handlers preferred.
  • Working knowledge of URAC standards preferred.
  • Intermediate planning & Organizing: ability to establish a plan/course of action and contingencies for self or others to meet current or future goals preferred.
  • Intermediate teamwork: ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result preferred.
  • 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 preferred.
  • 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 preferred.
  • Basic negotiation: ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise preferred.
  • 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 preferred.
  • Basic legal knowledge: understanding and application of state, federal and regulatory laws and statutes preferred.
  • Basic worker's compensation technical ability to apply available resources and technology to manage treatment plans preferred.

What We Offer:

  • 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.