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

$77,100.00 - $127,200.00

2

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 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. Demonstrate a clear understanding and ability to work within jurisdictional parameters within their assigned state preferred.

What is a Must Have?

• Registered Nurse; Licensed Practical Nurse or Licensed Vocational Nurse required.