• 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/claims summaries and applies appropriate established guidelines to requested treatment. Refers 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.
• Performs daily tasks within the appropriate established workflow processes, utilizes accepted guidelines and meets legislative and departmental timeframes.
• Maintain patient confidentiality in discussions of treatment, disease process and conditions.
• Routinely contacts providers to clarify treatment requests, examination findings, as well as obtain additional medical information as needed.
• Maintains clear, concise, and accurate documentation of requested medical treatments to include clinical findings, treatment guidelines, and determination.
• Provide appropriate notices to providers, injured workers, claims staff, and attorneys.
• Act as a medical resource in regards to utilization review to Claims Support Nurse, Bill Review, and Claims department.
• Foster a positive and close working relationship with other Company staff, including the claims staff, medical bill review, claims support nurse, special investigations, legal, liens, the call center, and client services.
• Communicate effectively with individuals outside the company, including clients, medical providers, and vendors.

WHAT WILL SET YOU APART

• A current RN license as well as 5+ years of recent, hands-on clinical experience in a Critical care unit such as; Medical Surgery, Emergency Room, ICU, Oncology, Orthopedics, Neuro or other similar settings.
• Certification and Education: Bachelor of Science Nursing degree (BSN), or Registered Nursing degree (RN) from four-year college or university, or an accredited college. Must have an active state license and is eligible to obtain additional state licenses.
• Experience: 5+ years of experience in acute care, emergency medicine, medical surgery, orthopedic practice or other medical environments where your experience could be applied to workers injured on the job.
• Technical Skills: Knowledge of current recognized evidence-based medicine guidelines, office operations, workflow analysis, and current technologies in telecommunications, data entry, and file management.
• Language Ability: Able to read, analyze, and interpret common scientific and technical journals, statutes, regulations, medical reports, medical coding, medical bills, financial reports, and legal documents. Able to respond to technical inquiries or complaints from Company employees, external sources, and regulatory or auditing entities.
• Reasoning Ability: Able to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Able to deal with problems involving several concrete variables in standardized situations.
• Computer Skills: Knowledge of Microsoft Office software. Able to perform independent internet medical research. Able to quickly master proprietary and vended software applications.