TPA Utilization Nurse

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.