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Position Summary:
The Supervisor of Workers' Compensation Utilization Review is responsible for overseeing and managing a team of Utilization Review Specialists. This role ensures the efficient and effective review of medical treatment requests for injured workers, adherence to evidence-based guidelines, and compliance with state-specific workers' compensation regulations. The Supervisor plays a crucial role in maintaining high-quality URAC standards, meeting department goals, and fostering a culture of continuous improvement.
Essential Duties and Responsibilities:
Possess excellent communication and organizational skills to interface with the client, claimants, and staff. Working well independently and setting priorities and working independently is essential.
Primary responsibilities include:
Operational Oversight
• Provide clinical, technical, and operational support and direction, including organization and monitoring of utilization review services.
• Assist with the daily operations of licensed and non-licensed professionals.
• Develop and oversee the implementation of utilization review practices and procedures with assigned team members.
• Ensure complete compliance with TRISTAR's policies and procedures.
• Participate in management team and supervisory meetings.
Quality Assurance and Compliance
• Dedicate 20% of total time to Quality Assurance meetings and URAC activities.
• Review quality audits and share results timely with associates, providing necessary education and training to improve performance.
• Ensure staff compliance with URAC and Utilization Review requirements and mandated regulatory requirements.
• Utilize jurisdictional knowledge of regulatory rules, statutes, and procedures to ensure compliance in assigned jurisdictions.
Training and Development
• Assist in training new staff and provide ongoing training to ensure staff expertise.
• Work collaboratively with the Manager and identified leadership to develop and implement performance measures.
• Monitor associates placed on performance improvement plans.
Communication and Client Relations
• Represent the company professionally to both internal and external customers and clients.
• Accurately answer questions regarding Utilization Review for clients, injured workers, and providers.
• Maintain communication among staff members in the department and communicate with the management team.
• Participate in client stewardship activities.
Special Equipment or Clothing:
Professional attire adhering to the Company Dress Code
Education:
Experience:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
Qualifications and Requirements:
Education and Licensure:
• Active, unrestricted RN licensure from the United States and in the state of hire, or active, compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC)
• Diploma, Associate, or bachelor’s degree preferred.
Certifications:
• CCM, CPHM, CMCN, or CDMS certification preferred.
Experience:
• Two years of Supervisory or Management experience
• Managed Care background in Worker's Compensation, Group Health, and/or Wellness preferred.
Knowledge and Skills:
• Proficiency in utilization management, quality improvement, discharge planning, and cost management
• Understanding of plan benefits information and authorization processes
• Familiarity with Group Health, Wellness, and/or Worker's Compensation law and practices
• Strong problem-solving abilities and capacity to handle various variables in complex situations.
• Excellent planning, organizing, conflict resolution, and negotiation skills.
• Outstanding interpersonal and organizational abilities
• Ability to set priorities and work independently.
Technical Skills:
• Proficient with Microsoft Office applications including Word, Excel, and PowerPoint
Skills and Attributes:
• Strong leadership and team management skills
• Excellent communication and interpersonal abilities
• Proficiency in quality assurance and process improvement
• Thorough understanding of workers' compensation regulations and utilization review practices
• Ability to manage multiple priorities in a fast-paced environment.
• Commitment to professional development and continuous improvement
Equipment Operated/Used:
• Essential Equipment: Desk, Telephone/Fax, Computer Keyboard, Mouse
• Essential Tools: Pens, pencil, computer, Keyboard
• Essential Vehicles: Valid driver’s license required.
Here are some of the benefits you can enjoy in this role:
Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]
| MENTAL AND PHYSICAL REQUIREMENTS |
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1. MENTAL EFFORT a. Reasoning development::Follow one- or two-step instructions; routine, repetitive task. Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. X Solve practical problems; variety of variables with limited standardization; interpret instructions. Logical or scientific thinking to solve problems; several abstract and concrete variables. Wide range of intellectual and practical problems; comprehend most obscure concepts. |
| b. Mathematical development: Simple additional and subtraction; copying figures, counting, and recording. |
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Add, subtract, multiply, and divide whole numbers. X Arithmetic calculations involving fractions, decimals, and percentages. Arithmetic, algebraic, and geometric calculations. Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination. Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application. |
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c. Language development: Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing. Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction. Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants. X Ability to compose original correspondence, follow technical manuals, and have increased contact with people. Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data. |
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2. PHYSICAL EFFORT a. Physical activity required to perform the job: Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. X Light work: a. Exerting up to 20 pounds of force occasionally b. Exerting up to 10 pounds frequently. Exerting a negligible amount of force constantly to move objects(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).Medium work:a. Exerting up to 50 pounds of force occasionallyb. Exerting up to 20 pounds of force frequentlyc. Exerting up to 10 pounds of force constantly to move objectsHeavy work:a. Exerting up to 100 pounds of force occasionallyb. Exerting up to 50 pounds of force frequentlyc. Exerting up to 20 pounds of force constantly to move objectsVery heavy work: |
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a. Exerting in excess of 100 pounds of force occasionally b. Exerting in excess of 50 pounds of force constantly to move objects c. Exerting in excess of 20 pounds of force constantly to move objects |
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b. Visual requirements necessary to perform the job: Far vision: clarity of vision at 20 feet or more X Near vision: clarity of vision at 20 inches or less X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are Color vision: ability to identify and distinguish colors Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point |
| 2. PHYSICAL EFFORT (cont.) | FREQUENCY |
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c. Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion. Balancing: Maintaining body equilibrium to prevent falling when walking, standing ,or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium. X Reaching: Extending hand(s) and arm(s) in any direction. X Standing: Particularly for sustained periods of time X Walking: Moving about on foot to accomplish tasks, particularly for long distances. |
OccasionallyOccasionallyOccasionallyOccasionallyOccasionallyOccasionallyOccasionally |
X Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.
X Kneeling: Bending legs at knee to come to a rest on knee or knees.
X Crouching: Bending the body downward and forward by bending legs and spine.
Crawling: Moving about on hands and knees or hands and feet.
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X Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward. X Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion. Foot Motion: Using feet to push pedals. X Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles .X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling. X Grasping: Applying pressure to an object with the fingers and palm. |
Occasionally Frequently Frequently Occasionally |
| 2. PHYSICAL EFFORT (cont.) | FREQUENCY | |
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X Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly. X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making find adjustments on machined parts. Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips. X Repetitive Substantial movements (motions) of the wrists, hands, Motion: and/or fingers. |
Frequently Frequently Frequently |
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| 3. WORKING CONDITIONS Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure. | ||
| WORKING CONDITIONENVIRONMENTALFACTOR | NATURE/REASONOF EXPOSURE | FREQUENCY |
| Dirt/Dust | ||
| Noise | ||
| Temperature extremes | ||
| Dampness | ||
| Vibrations |
| Equipment movement hazard |
| Chemicals/solvents |
| Electrical shock |
| Significant work pace/pressure |
| Odors/Fumes |
| Other (specify) |
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