Job Description

Job Description

POSITION PURPOSE:

The Medical Case Manager is a registered nurse with experience in the management and delivery of acute-care clinical services and in medical and disability case management. Case management is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality cost effective outcomes.

KEY ACCOUNTABILITIES:

* Conduct medical and disability case management consistent with professional standards and best practices for management of occupational and/or non-occupational illness/injury. (Assessment, Intervention, Evaluation).
* Facilitate medical access for the injured worker to the highest quality medical services utilizing appropriate provider networks.
* Communicate with employee, physician and employer.
* Effectively collaborate with customer and claims team partners.
* Ongoing analysis of cost containment program process and outcomes in order to maximize direction of injured worker to quality medical care.
* Coordinate medical care services.
* Execute case management assignments based on clearly defined referral criteria.
* Document use of best practice references such as standardized disability duration guidelines and medical management protocols.
* Advises and make recommendations regarding medical and disability management.
* Conduct medical technical and medical claims procedure orientation for new hires in the department.
* Organize and conduct training sessions for the workers' compensation claims management team.
* Manage and support multiple projects in a fast-paced environment

KNOWLEDGE AND EXPERIENCE:

Education Level:

* Licensed Registered Nurse (LRN) required
* Bachelors of Science in Nursing (BSN) preferred
* Certification in one of the following preferred: CCM, COHN, CPDM, CRRN, or equivalent

Experience Level:

* Minimum of six (6) years or more of experience in professional clinical practice (Ortho, Rehab, ICU/ER, or Occupational Health)
* Three (3) years in a case management role preferred

Skills and Experiences:

* Knowledgeable in workers' compensation - medical and disability case management and/or utilization review / utilization management practices and procedures desired.
* Extensive knowledge of medical and pharmaceutical terminology.
* Computer proficiency with basic claims system and Microsoft Office, including Word and Excel.
* Successful experience in conflict management and negotiations.
* Self-motivated, excellent oral and written communication skills, documentation and follow-up.
* Knowledge of related employment benefits (ADA, FMLA, state disability legislation, LTD, SDI, group health benefits) and how they interact with workers compensation benefits.
* High degree of initiative; proven team player.

TRAVEL REQUIREMENTS: Less than 15%.

PHYSICAL ENVIRONMENT: Office building

Disclaimer:

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this job classification. They are not intended to be construed as an exhaustive list of all responsibilities and skills required of personnel so classified.