Medical Case Manager

Quick Facts

Remote in Pennsylvania

Role: Telephonic Medical Case Manager (RN)

Salary range: $80,000.00–90,000.00

Description

Provides comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider and employer. Nurses partner with adjusters to develop a personalized holistic approach for each claim, including utilization review, pharmacy oversight and care coordination.

Responsibilities

• Determine whether all aspects of a patient’s care are medically necessary and appropriately delivered
• Perform utilization review activities prospectively, concurrently or retrospectively per jurisdictional guidelines
• Send letters to prescribing physician(s) and refer to physician advisor as necessary
• Maintain accurate, comprehensive documentation of case management activities in the case management system
• Coordinate the individual’s treatment program to maximize quality and cost-effectiveness of care (including direction of care to preferred provider networks where applicable)
• Discuss job duties and medical limitations with employer, injured employee and/or provider; help coordinate modifications to job duties based on functional assessment
• Ensure injured employees receive appropriate level and intensity of care using medical and disability duration guidelines; assist adjusters in managing medical treatment to drive resolution
• Communicate with claims adjuster, client, vendor, supervisor and other parties to coordinate appropriate medical care and return to work
• Conduct clinical assessment from medical/pharmacy reports and case files, including psychosocial needs, cultural implications and support systems
• Assess the treatment plan to identify barriers, clarify realistic goals, and seek alternatives
• Partner with the adjuster to develop medical resolution strategies toward maximal medical improvement or appropriate outcome
• Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim
• Engage specialty resources as needed (behavioral health program, physician advisor, peer reviews, medical director)
• Provide input on medical treatment and recovery time to assist evaluation of claim reserves
• Maintain client privacy and confidentiality; promote client safety and advocacy; adhere to ethical, legal, accreditation and regulatory standards
• Assist with training/orientation of new staff as requested
• Support organizational quality program(s)
• Other duties may be assigned

Requirements

• Active unrestricted NY RN license (PA compact preferred)
• BSN from an accredited college/university or equivalent work experience preferred
• Certification in case management, pharmacy, rehabilitation nursing, or related specialty highly preferred
• Ability to acquire and maintain required Professional Certifications and Licenses to comply with state laws (preferred to obtain within 3–6 months)
• Written and verbal fluency in Spanish and English preferred
• 5 years of related experience or equivalent combination of education/experience, including two years of direct clinical care OR two years of case management/utilization management
• Knowledge of workers’ compensation laws and regulations
• Knowledge of case management practice
• Knowledge of injuries, periods of disability, and needed treatment
• Knowledge of URAC standards, ODG, utilization review, and state workers compensation guidelines
• Knowledge of pharmaceuticals for pain, pain management process, and drug rehabilitation
• Knowledge of behavioral health
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Leadership/management/motivational skills
• Analytic and interpretive skills
• Strong organizational skills
• Excellent interpersonal and negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

Benefits

• Medical & Dental Plans
• Life Insurance (eligible spouses & children)
• Health Care Flexible Spending
• Dependent Care
• 401k Savings Plans
• Paid Time Off