Utilization Review Nurse

Who Are We?

Taking care of our customers, our communities and each other. That’s the Travelers Promise. By honoring this commitment, we have maintained our reputation as one of the best property casualty insurers in the industry for over 170 years. Join us to discover a culture that is rooted in innovation and thrives on collaboration. Imagine loving what you do and where you do it.

Job Category

Claim, Nurse - Medical Case Manager

Compensation Overview

The annual base salary range provided for this position is a nationwide market range and represents a broad range of salaries for this role across the country. The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment. As part of our comprehensive compensation and benefits program, employees are also eligible for performance-based cash incentive awards.

Salary Range

$81,500.00 - $134,500.00

Target Openings

1

What Is the Opportunity?

This position is 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. Responsible for helping to ensure the appropriate treatment is directly related to the compensable injury and for adhering to multi-jurisdictional Utilization Review criteria.

What Will You Do?

• 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.
• In order to perform the essential functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, license(s) must be obtained within three months of starting the job and obtain ongoing continuing education credits as mandated.
• Perform other duties as assigned.

What Will Our Ideal Candidate Have?

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