Utilization Review Nurse

1 week ago

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

We are seeking a highly skilled Utilization Review Nurse to join our team at Travelers Insurance. As a Utilization Review Nurse, you will play a critical role in ensuring that medical treatment is necessary and reasonable for workers' compensation claims.

Key Responsibilities
  • Conduct in-house utilization review to determine medical necessity for prospective, concurrent, retrospective, and appeal treatment requests.
  • Evaluate medical treatment to determine whether it is reasonable, necessary, and causally related based on jurisdictional guidelines.
  • Submit accurate billing documentation on all activities as outlined in established guidelines.
  • Engage specialty resources, as needed, to reach a 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 providers to ensure the injured employee is actively participating in a viable treatment plan.
  • Keep claim professionals 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.

  • Utilization Review Coordinator

    1 month ago

    Buffalo, New York, United States StateJobsNY Full time

    Job Title: Utilization Review CoordinatorBuffalo Psychiatric Center is seeking a skilled Utilization Review Coordinator to analyze and evaluate the quality, effectiveness, and efficiency of psychiatric and medical services provided to individuals diagnosed with mental illness.Responsibilities:Review clinical records for completeness and accuracy to ensure...

  • Utilization Review Nurse Specialist

    1 month ago

    Buffalo, New York, United States VetJobs Full time

    Job Title: Utilization Review NurseAt VetJobs, we are seeking a skilled Utilization Review Nurse to join our team. As a Utilization Review Nurse, you will play a critical role in ensuring that medical treatment is reasonable, necessary, and causally related to the compensable injury.Key Responsibilities:Interpret complex medical information to determine...

  • Clinical Utilization Review Nurse

    2 weeks ago

    Buffalo, New York, United States Independent Health Full time

    Unlock Your PotentialWe're seeking a skilled Utilization Review Nurse to join our team at Independent Health. As a Utilization Review Nurse, you will play a critical role in ensuring that our members receive the necessary care and services to achieve optimal health outcomes.About the RoleThe Utilization Review Nurse will be responsible for performing...

  • Utilization Review Nurse Specialist

    1 month ago

    Buffalo, New York, United States Travelers Insurance Full time

    Job SummaryThis role is responsible for conducting in-house utilization review with a focus on determining medical necessity for prospective, concurrent, retrospective, and appeal treatment requests for workers' compensation claims.Key ResponsibilitiesInterpret routine, complex, or unique medical information to evaluate medical treatment and determine...

  • Utilization Review Nurse

    2 months ago

    Buffalo, New York, United States Travelers Insurance Full time

    Job SummaryWe are seeking a skilled Utilization Review Nurse to join our team at Travelers Insurance. As a Medical Case Manager, you will play a critical role in ensuring that our customers receive the necessary medical treatment for their workers' compensation claims.Key ResponsibilitiesConduct in-house utilization review to determine medical necessity for...

  • Utilization Review Nurse

    2 weeks ago

    Buffalo, New York, United States Travelers Insurance Full time

    Job SummaryTravelers 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...

  • Clinical Review Nurse

    2 weeks ago

    Buffalo, New York, United States Independent Health Full time

    Unlock Your PotentialWe're committed to fostering a culture of growth and inclusion. As a Utilization Review Nurse at Independent Health, you'll have the opportunity to develop your skills and expertise in a dynamic and supportive environment.About the RoleThe Utilization Review Nurse performs clinical reviews to determine the medical necessity of requested...

  • Clinical Review Nurse

    1 month ago

    Buffalo, New York, United States Independent Health Association Full time

    Job SummaryWe are seeking a skilled Utilization Review Nurse to join our team at Independent Health Association. As a Utilization Review Nurse, you will play a critical role in ensuring that our members receive high-quality, cost-effective care.Key ResponsibilitiesPerform clinical reviews to determine the medical necessity of requested servicesObtain and...

  • Clinical Review Nurse

    2 weeks ago

    Buffalo, New York, United States Independent Health Full time

    Job SummaryWe are seeking a skilled Clinical Review Nurse to join our team at Independent Health. As a Utilization Review Nurse, you will play a critical role in determining the medical necessity of requested services.Key Responsibilities Perform clinical reviews to determine medical necessity of requested services Obtain clinical information and utilize...

  • Clinical Reviewer

    1 week ago

    Buffalo, New York, United States Independent Health Association Full time

    Job SummaryWe are seeking a highly skilled Clinical Reviewer to join our team at Independent Health Association. As a Clinical Reviewer, you will be responsible for the collection and review of medical records specific to quality complaints/grievances and appeals.Key ResponsibilitiesInvestigate quality complaints/grievances and appeals, document research of...

  • Clinical Reviewer

    1 week ago

    Buffalo, New York, United States Independent Health Association Full time

    Job SummaryWe are seeking a highly skilled Clinical Reviewer to join our team at Independent Health Association. As a Clinical Reviewer, you will play a critical role in ensuring the quality and accuracy of medical records and coverage determinations.Key ResponsibilitiesInvestigate and research clinical appeals, complaints, and grievances to ensure coverage...

  • Surgical Services Data Reviewer

    2 weeks ago

    Buffalo, New York, United States ECMC Full time

    Job SummaryThis role involves collecting and analyzing medical data related to surgical services for submission to regulatory agencies and performance improvement initiatives. The incumbent will work under the supervision of the Vice President of Surgical Services to ensure accurate and timely data submission, maintain related records and databases, and...

  • Travel Nurse RN

    4 weeks ago

    Buffalo, New York, United States Travel Nurse Source Full time

    Travel Nurse RN Job OpportunityWe're seeking a skilled Admin/Mgmt RN to join our team at QS Nurses in Oneida, New York. As a travel nurse, you'll have the chance to work in various healthcare settings, gaining exposure to diverse patient populations, medical procedures, and healthcare systems.Benefits of Travel NursingDiverse range of assignments on your...

  • Nurse Liaison Specialist

    4 weeks ago

    Buffalo, New York, United States Ubiquity Inc. Full time

    Job Title: Nurse LiaisonWe are seeking a highly skilled and experienced Nurse Liaison to join our team at Ubiquity Inc. As a key member of our healthcare team, you will play a critical role in shaping the future of healthcare by providing expert resource management, utilization review, and compassionate patient care.Job Summary:The Nurse Liaison will be...

  • Cardiology Nurse Specialist

    2 weeks ago

    Buffalo, New York, United States Northtowns Cardiology Full time

    Job Summary:Northtowns Cardiology is seeking a skilled Registered Nurse to join our team in our fast-paced outpatient Cardiology practice. As a Cardiology Nurse Specialist, you will be responsible for conducting patient screenings, administering medications, and reviewing medical records for quality assurance measures. Key Responsibilities:Conduct patient...

  • Nurse Practitioner PRN

    2 weeks ago

    Buffalo, New York, United States Chenega Corporation Full time

    Job SummaryChenega Corporation is seeking a highly skilled Nurse Practitioner to perform medical histories, physical examinations, and reviews of required medical tests and documentation pertaining to consultations and medical histories on applicants for the Armed Forces.ResponsibilitiesConduct thorough medical histories, physical examinations, and reviews...

  • Cardiology Nurse Specialist

    2 weeks ago

    Buffalo, New York, United States Northtowns Cardiology Full time

    Join Our Team as a Cardiology Registered NurseNorthtowns Cardiology is seeking a skilled and compassionate Registered Nurse to join our team in our fast-paced outpatient Cardiology practice. As a key member of our team, you will be responsible for providing high-quality patient care and contributing to the success of our practice.Key Responsibilities:Conduct...

  • Care Management Director

    7 days ago

    Buffalo, New York, United States ECMC Full time

    Care Management Director Job DescriptionJob Summary: We are seeking a highly skilled Care Management Director to oversee the nursing case management, utilization review, and quality management functions in our Care Management Department at ECMC. The ideal candidate will have a strong background in professional nursing and experience in case management,...

  • Nurse Liaison

    2 weeks ago

    Buffalo, New York, United States Ubiquity Full time

    Job DescriptionAre you a seasoned Registered Nurse with a passion for shaping the future of healthcare?As a Nurse Liaison, you will be an expert in resource management, a master of utilization review, and a compassionate partner for patients and their support network. You will be responsible for an assigned caseload at acute and post-acute care facilities....

  • Nurse Liaison Specialist

    2 weeks ago

    Buffalo, New York, United States Ubiquity Full time

    Job SummaryUbiquity is seeking a highly skilled Nurse Liaison to join our team. As a key member of our healthcare team, you will be responsible for facilitating the transition of patients from acute care settings to post-acute care facilities. Your expertise in utilization management and clinical knowledge will be essential in ensuring optimal patient...