Telephonic Medical Case Manager (Workers' compensation)

POSITION SUMMARY: The medical case manager provides telephonic case management in a workers' compensation environment, coordinating resources and cost-effective options on a case-by-case basis to facilitate quality individualized treatment goals and return to work placement.

ESSENTIAL DUTIES AND RESPONSIBILITIES: Possess excellent communication and organizational skills to interface with the client, claimants, and staff. Work well independently and set priorities.

Primary responsibilities include:

• Provide telephonic outreach for assessment and follow-up for case communication and coordination to include assessing, planning, implementing, coordinating care
• Conducts and documents initial assessment with the injured worker, employer, and provider and maintains regular contact with all parties involved to facilitate communication and formulate a clinical case plan

• Reviews case records and reports, collects and analyzes data, evaluates client's medical status, and defines needs and problems in order to provide proactive case management services
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• Assessment of medical records for appropriateness of treatment and level of care being provided. Referral to the Medical Director if appropriate within the established timeframes
• Facilitate timely return to work date coordinating RTW with the claimant, employer, and physicians
• Maintains contact and communicates updated activity with all parties involved with the case
• Telephonically monitor medical appointments of the injured worker to address RTW, current treatment plan and, identify potential issues and promote positive treatment outcomes. Negotiate treatment plan with treating physician

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  Additional Functions and Responsibilities

• Demonstrates ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards
• Maintain minimum billing and established template documentation standards adhering to URAC standards and company policy and procedures
• Reporting billing hours in accordance with case activity and billing practices
• Maintain confidentiality- Knowledge of laws and regulations pertaining to HIPPA and PHI
• Other job duties as assigned

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• EQUIPMENT OPERATED/USED:

  Essential Equipment: Desk, Telephone/Fax, Computer Keyboard, Mouse, System Applications

  Essential Tools: Pens, pencil, computer, Keyboard

  Essential Vehicles: N/A

   

  SPECIAL EQUIPMENT OR CLOTHING:

  Professional attire adhering to the Company Dress Code

   

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.

• Three or more years of diverse clinical experience in caring for acutely ill patients with multiple disease conditions 
• Three or more years of Managed Care and or Worker's Compensation experience
• Knowledge of utilization management, quality improvement, discharge planning, and cost management
• Background in state worker's compensation law and practices desirable
• Ability to solve practical problems and deal with a variety of variables 
• Possess planning, organizing, conflict resolution and negotiating skills 
• Excellent interpersonal skills and excellent organizational skills.
• Proficient with Microsoft Office applications including Word, Excel, and Power Point

• Education:

• Diploma, associate or bachelor’s degree in nursing, Master's level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred
• Current, unrestricted RN license required
• CCM, CPDM, COHN or CDMS certification preferred