TPA VP Managed Care
Company: USI Insurance Services
Posted on: May 18, 2019
General Description: Manages activities of the managed care
department of the TPA (FutureComp). This includes medical case
specialists who are responsible for workers compensation and
disability claims case management and utilization review, including
case management of medical aspects of workers compensation and
disability claims and 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. Manages
staff, provides direction, sets goals, evaluates results and
ensures that overall department goals are attained. Ensures that
ongoing activities are performed according to established policies
and procedures as well as applicable state regulations and specific
carrier and client instructions. Ensures that own work, as well as
work of any employees supervised, is in compliance with applicable
laws, regulations and guidelines.
- Manages activities of TPA medical case specialists responsible
for workers compensation and disability claims case management and
utilization review according to established policies and procedures
and applicable legal and regulatory guidelines.
- Manages staff directly and through subordinate supervisors,
providing direction, setting goals, evaluating results and ensuring
that overall department goals are attained. Provides leadership,
coaching, counseling, training and guidance to staff and assigns
responsibilities. Develops, assigns and monitors plans to ensure
completion of goals and objectives and meeting deadlines. Ensures
new staff members are trained in department policies, practices and
- Develops department policies and procedures in coordination
with division management, including protocols and standards for
case management services and utilization review; ensures adherence
to policies, procedures, standards and guidelines. Coordinates
department compliance with overall division guidelines as well as
regulatory agencies. Manages development and maintenance of
procedures manual. Assists with development and administration of
- 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
- Assists staff with complex aspects of work 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
personally as workload requires. Co-signs casework submitted by
staff as required. Responds to requests from insurance carriers,
medical personnel, attorneys and others.
- Coordinates scheduling and assignment of work and other
activities to ensure that key deliverables meet established
guidelines. Assesses internal and external customer needs and
manages activities to ensure services are delivered in the most
efficient way possible.
- Coordinates department technology support. Monitors performance
of systems and communicates feedback to division management,
internal technology personnel and directly to vendors as
appropriate. Integrates new systems and upgrades into department
operations as needed.
- Reviews and evaluates department activities on a regular basis,
ensuring that established policies and procedures are being
followed. Ensures ongoing department communications with sales,
claims and management as well as other Company departments to
exchange account and other information. Provides management with
regular updates on department performance; takes corrective action
- Maintains knowledge of current developments in the managed care
industry, including regulatory issues and guidelines and technology
changes; evaluates the impact of current trends and events on
department activities, alerts staff to developments and develops
recommendations for consideration with division management in
reviewing policies and procedures. Shares information with staff as
- Participates in civic activities to promote growth and
development of the community and a positive image for the
- Participates in special projects and performs additional duties
- 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 minimum of 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
- Management skills, with ability to coach, train and motivate
- Supervisory experience required.
- Highly organized, with ability to manage work involving large
- 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
- Strong organizational skills required.
- Strong negotiation skills required.
Work is performed in a climate controlled office environment with
minimal noise and limited to no exposure to chemicals or toxins.
Employees operate office equipment including; telephone - headset,
Computer, computer monitors, keyboard, mouse, copier, scanner and
mail machine. Physical tasks of job include; walking, sitting,
standing and bending.
Analysis of Physical Demands:
- Constantly (over 66% of time) work performed requires employees
to use repetitive hand motions such as typing, using a keyboard,
and sitting at a desk.
- Frequently (34%-66% of time) work performed requires employees
to handle and grasp things, walk on normal surfaces, stand and
- Occasionally (1%-33% of time) work performed requires employees
to drive to client appointments, have repetitive foot movements,
walk on uneven or slippery surfaces to and from work and
occasionally reach outward to grab things and bend.
- Rarely (
Keywords: USI Insurance Services, Chicopee , TPA VP Managed Care, Executive , Chicopee, Massachusetts
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