Utilization Review Nurse - Workers' Compensation - Buffalo, NY
: Job Details :

Job Description ATTENTION MILITARY AFFILIATED JOB SEEKERS - Our organization works with partner companies to source qualified talent for their open roles. The following position is available to Veterans, Transitioning Military, National Guard and Reserve Members, Military Spouses, Wounded Warriors, and their Caregivers. If you have the required skill set, education requirements, and experience, please click the submit button and follow the next steps. Unless specifically stated otherwise, this role is On-Site at the location detailed in the job post. 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 160 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. 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 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. Additional Qualifications/Responsibilities What Will Our Ideal Candidate Have? Bachelor's Degree or Juris Doctorate or Paralegal Certification from an ABA-Certified program preferred. 4 years bodily injury litigation claim handling experience preferred. Advanced level knowledge in coverage, liability and damages analysis and has a thorough understanding of the litigation process, relevant case and statutory law and expert litigation management skills preferred. Extensive claim and/or legal experience and technical expertise to evaluate severe and complex claims preferred. Able to make independent decisions on most assigned cases without involvement of supervisor preferred. Thorough understanding of business line products, policy language, exclusions, ISO forms, and effective claims handling practices preferred. Openness to the ideas and expertise of others actively solicits input and shares ideas. Strong customer service skills. - Intermediate Demonstrated coaching, influence and persuasion skills.- Intermediate Strong written and verbal communication skills are required so as to understand, synthesize,interpret and convey, in a simplified manner, complex data and information to audiences with varying levels of expertise.- Intermediate Strong technology aptitude; ability to use business technology tools to effectively research, track, and communicate information. - Intermediate Attention to detail ensuring accuracy -Intermediate Job Specific Technical Competencies: Analytical Thinking - Intermediate Judgment/Decision Making - Intermediate Communication - Intermediate Negotiation -Advanced Insurance Contract Knowledge - Advanced Principles of Investigation - Advanced Value Determination - Advanced Settlement Techniques - Intermediate Legal Knowledge - Intermediate Medical Knowledge - Intermediate What is a Must Have? High School Degree or GED required with a minimum of 3 years bodily injury litigation claim handling or comparable claim litigation experience.