Buffalo, New York
Solid reputation, passionate people and endless opportunities. That's Travelers. Our superior financial strength and consistent record of strong operating returns mean security for our customers - and opportunities for our employees. You will find Travelers to be full of energy and a workplace in which you truly can make a difference.
Under moderate supervision, conduct 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. This job does not manage others This job works under Moderate Supervision: Incumbent performs standard and routine assignments independently to conclusion; unusual problems which may require exceptions to procedures or processes are referred to the supervisor.
Primary Job Duties & 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. Perform other duties as assigned.
Registered Nurse; Licensed Practical Nurse or Licensed Vocational Nurse required.
In order to perform the essential job functions of this job, acquisition and maintenance of Insurance License(s) may be required to comply with state and Travelers requirements. Generally, License(s) are required to be obtained within three - six months of starting the job.
Education, Work Experience & Knowledge
Working knowledge of medical causation and relatedness preferred. Working knowledge of jurisdiction-specific medical guidelines preferred. Prior clinical experience preferred.
Job Specific & Technical Skills & Competencies
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. Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state preferred.
Operates standard office equipment (Continuously) Sitting (Can stand at will) (Continuously) Use of Keyboards, Sporadic 10-Key (Continuously)
Equal Employment Opportunity Statement
Travelers is an equal opportunity employer.
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