Workers' Compensation Utilization Review Coordinator
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.
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
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
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.
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):
Certified Case Manager Certificate
Job Professional and Managerial
Primary Location TN-Nashville-Crystal Terrace
Organization Corporate Health Services 108613