TPA Medical Case Manager

General Description :

Manages medical aspects of workers compensation and disability claims for Third Party Administration (TPA) accounts by coordinating with patients, physicians, other health care providers and employers to facilitate positive patient outcomes, timely return to work if applicable and efficient claims resolution.

Responsibilities :

• Manages activities of workers compensation and disability claims, case management and utilization review according to established policies and procedures and applicable legal and regulatory guidelines.
• Manages ongoing managed care activities, including case management of medical aspects of workers compensation and disability claims for TPA accounts by coordinating with patients, physicians, other health care providers and employers to facilitate positive patient outcomes, timely return to work if applicable and efficient claims resolution and utilization review, gathering demographic and clinical information on inpatient admissions and outpatient treatment, certifying the medical necessity of the services and assigning appropriate length of stay and other treatment plans.
• Presents case management and utilization review information and overviews to prospects and clients as needed.
• Assists adjuster with complex medical aspects as necessary. Resolves escalated issues and problems by conferring with staff, management, other internal departments, outside contacts and clients as necessary.

Performs case management and other activities as workload requires. Responds to requests from insurance carriers, medical personnel, attorneys and others.

• Assesses internal and external customer needs and manages activities to ensure services are delivered in the most efficient way possible.
• Reviews and evaluates medical claim activities on a regular basis, ensuring that established policies and procedures are being followed.
• Ensure ongoing department communications with sales, claims and management as well as other Company departments to exchange account and other information.
• Maintains knowledge of current developments in the managed care industry, including regulatory issues and guidelines changes.
• Participates in special projects and performs additional duties as required.
• Contributes to a positive, ethical and respectful working environment and communicates openly with others. Models Company culture both internally and externally.

Knowledge, Skills and Abilities :

• 4-year nursing degree or the equivalent combination of education and work experience required. Masters degree in business, healthcare or other related field preferred.
• A 5 to 10 years workers' compensation and disability case management experience required.
• Excellent understanding of managed care industry practices, including medical case management, utilization review and related legal and regulatory guidelines.
• Strong clinical background in orthopedics, neurology or rehabilitation.
• Highly organized, with ability to manage work involving large client volume.
• Project management skills.
• Strong understanding of managed care technology applications.
• Excellent communication skills, both verbal and written.
• CCM, CRS or CDMS certification required.
• State licensing in jursdication handled
• Superior written and oral communication skills.
• Ability to work well in a team environment.
• Must have strong analytical thinking and problem-solving skills.
• Strong organizational skills required.

Why USI?

With more than $2.5 billion in revenue and over 10,000 associates across 200+ offices nationwide, USI is one of the largest insurance brokerage and consulting firms in the world.

At USI, we have created one of the most dynamic personal and professional development cultures in the industry. We invest heavily in our associates, and we take pride in celebrating their growth and success through our one-of-a-kind employee reward and recognition programs.

We invite you to learn more about what makes USI an exceptional place to work!

Unrivaled Resources and Support

What truly distinguishes USI as a premier insurance brokerage and consulting firm is the

a game-changing value proposition that delivers to clients a robust set of risk management and benefit solutions with bottom-line financial impact.

USI ONE® represents Omni, Network, Enterprise the three key elements that set USI apart from the competition. Through USI ONE, we develop strategic, timely and effective risk management and benefit programs in terms that are easy to understand, and we demonstrate how the solutions can have a positive economic impact.

Industry-Leading Programs, Rewards, and Recognition

In addition to competitive pay, incentives, and benefits, USI recognizes associates through our Summit Awards program, rewarding excellence in those who build our brand each day.

USI offers that recognize outstanding achievement and help our associates lead healthy, productive lives. We turn care into action with our award-winning wellness program, college scholarships for associates' children, and financial help in times of need.

Deep Community Engagement

We are committed to giving back to our local communities and supporting a culture of environmental sustainability. From sharing our time, talent, and resources to support local non-profit organizations, animal shelters, and environmental beautification and restoration projects to partnering with eco-conscious vendors and taking steps to reduce our own environmental footprint we’re working to build a better future.

Committed to a Diverse, Equitable, and Inclusive Workplace

Our award-winning diversity, equity, and inclusion program educated our associates to help them better understand and serve our clients, prospects, fellow team members, and local communities through curated education and training resources, employee support programs, and community outreach initiatives to build a more diverse, equitable, and inclusive culture.

Nationally Recognized as a Top Insurance Employer

Recognized as one of Insurance Business America’s Top Insurance Employers for six consecutive years (2018-2023).

• Named to Business Insurance’s annual list of the Best Places to Work in Insurance four years in a row (2020-2023).
• Recipient of the American Heart Association’s Gold Status for a maintaining a culture of health and well-being five years in a row (2018-2022).
• Visit our for a complete list of industry awards and recognitions!

USI is committed to providing a full-suite of competitive benefits for our growing population and its diverse needs. We offer a wide range of health, welfare and financial benefits including medical, wellness, dental and vision, 401(k), flexible spending and health savings accounts, short and long-term disability, life insurance and other unique employer-sponsored and voluntary programs.

USI also offers a generous paid time off policy, paid family leave benefit as well as paid holiday time .

$72,000-$105,000