Workers' Compensation Utilization Review Coordinator

Nashville, Davidson County
Aug 01, 2014


To develop, implement, coordinate, monitor, and evaluate the operation of Utilization Review for the Office of Risk Management. To facilitate proactive procedures that assure the injured worker receives the quantity and quality of services at the appropriate time in the appropriate setting to be consistent with their medical care needs. To provide a mechanism to conduct precertification review, admission review, continued stay review/concurrent review, discharge planning and case management based on appropriate guidelines and State mandates. To oversee the day to day operations of worker's compensation utilization review.

Key Functions and Expected Performances:


Coordinates and supports the utilization review process

         Facilitates the utilization review process for the Office of Risk Management

         Plans, develops, and implements procedures to fulfill the mandated requirements for an effective and timely utilization review system.

         Confers with physicians, administrative personnel, case managers and other ancillary departments to coordinate, obtain information, and answer questions concerning the necessity for utilization review.

         Reviews injured worker medical information as well as recommended treatment and provides timely determination of approvals/denials based on medical necessity and utilizing appropriate medical guidelines.

         Collaborate with Physician Consultant when recommended treatment does not fall within medical guidelines.

         Develops databases for the compilation of information from medical charts concerning particular diagnoses, problems, procedures, or practitioner categories as directed for medical care evaluation quality studies.

         Utilize the TN Department of Labor online reporting system for each review.

Coordinates and supports services for the Office of Risk Management

         Acts as a consultant to the Office of Risk Management, VMG, and hospital faculty/staff regarding issues related to the utilization review process.

         Places copies of UR letters into the "Marsh STARs" system.

         Provides UR decision to the bill review company.

         Coordinates Peer Review/Second Opinion/Independent Medical Examination appointments as necessary

Provides education and support

         Assists in dissemination of Department of Labor changes and updates

         Assists in orientation of new staff

         Provides education to VMG and hospital staff regarding UR processes.

         Provides education to injured Vanderbilt employees regarding the UR process as needed.

         Support the Physician Consultant in the performance of the UR process.

Professional Development

         Participates in conferences/in-services for continued education requirements for Certified Case Manager and networking opportunities (MidSouth Worker's Compensation Association, Middle TN Case Managers Assoc., etc.)

         Develops proficiency in software programs utilized in case management

         Obtains/evaluates/synthesizes new information and knowledge/research applicable to worker's compensation

Special Projects

         Assists with special projects as assigned by Department Leadership.

         Coordinates Blood and Body Fluid follow-ups for work related (non-Vanderbilt employees) injuries seen in the emergency department.

         Acts as Orthopedic Liaison

Quality Assurance

         Develops and implement new QA indicators as needed for the Department.

         Performs QA audits on a quarterly basis

         Monitors QA indicators for continued relevance and develop new indicators as appropriate

         Monitors HIPAA compliance for Department.

         Reports QA results quarterly to Department Leadership and at staff meeting.

Supervise Worker's Compensation Case Management Services

         Monitors day-to-day activities and assist staff with time management.

         Continue staff development by encouraging staff to participate in training opportunities. Monitors CEU status for licensed/credentialed staff and monitors compliance for State Regulations regarding licensed/credentialed staff

         Develops/implements/reviews/revises case management processes and work flow and make ongoing recommendations for best practice.

         Provides quarterly rounding on staff and conduct annual staff performance reviews.

         Maintains level of expertise required to support staff in their case management activities. Acts as resident expert.


Basic Qualifications

Preferred Education, Skills, and Experiences:

         Graduate of an accredited discipline specific program and 3 years of experience or the equivalent required

         Must have current RN licensure and Certified Case Manager Certification

         Previous experience with Utilization Review and/or Worker's Compensation preferred

         Ability to interact collaboratively with physicians and staff across multiple departments

         Strong organizational and time management skills

Licensure, Certification, and/or Registration (LCR):

Registered Nurse

Certified Case Manager Certificate

Job Professional and Managerial

Primary Location TN-Nashville-Crystal Terrace

Organization Corporate Health Services 108613