Nurse Case Manager Workers Compensation (Telephonic)

The Nurse Case Manager collaborates with Workers’ Compensation claims representatives, medical providers, employers and injured employees to develop treatment plans focused on return to work and achieving maximum medical improvement within established medical and disability guidelines. This is achieved through overseeing all medical aspects of workrelated injury claims by implementing the nursing process, including assessment, planning, coordination, intervention and evaluation. In collaboration with claims representatives, the Nurse Case Manager will be responsible for developing medical and disability management strategies for an assigned caseload within jurisdictional requirements. Caseload severity may range from medical only to catastrophiccomplex claims across multiple jurisdictions. The Nurse Case Manager will also complete liability nurse reviews and serve as a clinical resource to Commercial Auto and Liability claims teams. This position will report to the Workers’ Compensation Claims Manager.

• Location: This is a fulltime remote position. This position may require occasional travel to attend trainings andor other related department meetings.

• Job Responsibilities

  • Triage incoming Workers’ Compensation claims and assign claims to claims staff based on injury severity
  • Provide medical case management through telephonic communication with injured employees, physicians, employers, health care providers, vocational rehabilitation consultants and others
  • Effectively manage caseload of medicaldisability cases to achieve optimal outcomes and facilitate claim resolution
  • Evaluate injured employees’ responses to medical treatment and using clinical expertise, recommend alternative treatment or care options as needed
  • Estimate medical treatment and recovery time guidelines to assist Claims with evaluating claim reserves
  • Serve as a clinical resource to claims staff
  • Protect the confidentiality of protected health information and other confidential information
  • Work with employers and physicians to develop modified job duties when practical to facilitate early return to work
  • Request and review medical records and treatment plans for appropriateness and medical necessity
  • Review pharmacy portal for medication management
  • Educate injured workers on treatment plans as needed to enhance adherence to the treatment plan and monitor progress towards maximum medical improvement
  • Collaborate with claims representative for utilization review services as appropriate
  • Clinically evaluate the recovery needs of an injured employee including discharge planning needs and facilitate referrals to durable medical equipment, transportation and home health vendors as applicable
  • Effective documentation of nurse case management activities, including activity updates and medical and disability case management strategies
  • Schedule independent medical exams or second opinions as appropriate, as well as routine medical appointments as required by jurisdiction
  • Maintain regular contact with injured employees, claims representatives, providers and employers to ensure understanding of the treatment plan by all parties
  • Obtain approval for injured employee contact on represented cases
  • Assist in negotiating pricing for medical equipment and medical services as needed
  • Apply advanced knowledge of injuries, comorbidities, medications, and treatment options to provide guidance on the treatment plan
  • Partner with claims representatives on coordination of treatment and services under the policy as allowed by the jurisdiction
  • Regularly communicate with injured employee and providers. Encourage the injured employee to participate in the recovery plan.
  • Identify injury and disability triggers requiring the engagement of field nurse case management
  • Complete referrals to field vendors and partner with vocational rehabilitation specialists and field nurse case managers to achieve optimal claim outcomes
  • Complete Liability Nurse Reviews on Commercial Auto and Liability claims with a goal of flagging missing records and inconsistencies in records, identifying comorbid and nonrelated conditions, addressing causationmechanism of injury, and evaluating medical records for excessiveduplicativeor unrelated treatment
  • Assist with department training needs
  • Additional duties and special projects as assigned
  • Duties are not limited to the above and may expand over time

  • Qualifications

    • Licensed Registered Nurse with a current unrestricted license in a compact nursing state required (Applicants with unrestricted nursing licenses in the following states will be considered: Alabama, Arizona, Arkansas, Colorado, Delaware, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, Washington, Wisconsin, Wyoming)
    • Certification as a CCM, CIRS, or other Case Management certification, where required (If not certified, must obtain within one year of hire)
    • 3+ years clinical experience, preferably in orthopedics, rehabilitation, critical care, or emergency room
    • Ability to work independently and collaboratively within a virtual office environment
    • Excellent verbal and written communication skills
    • Must have reliable internet
    • Selfmotivated and flexible
    • Strong customer service skills
    • Excellent written and verbal communication skills
    • Ability to independently manage workload, including prioritizing, and managing assignments to meet deadlines
    • Proficiency with MS Word, Excel, Outlook, Teams, Slack, Zoom and internet applications
    • Highly attentive to details
    • Able to work under pressure and execute good judgment in sensitive situations

    • About Us

      biBerk is where commercial insurance buyers can obtain coverage for their businesses from insurers of the Berkshire Hathaway group of Insurance Companies, one of the best capitalized insurance groups in the world. Our ultimate parent, Berkshire Hathaway Inc. (berkshirehathaway.com) is a holding company with diversified interests in a host of industries, including insurance, energy, transportation and manufacturing. Most policies issued through biBerk.com will be underwritten by Berkshire Hathaway Direct Insurance Company (BHDIC), which is an AM Best rated A++ insurer.

      BHDIC is domiciled in Omaha, Nebraska. BHDIC and the team at biBerk are focused on helping small business owners quickly and easily buy affordable insurance directly from a financially strong insurance company they can trust.

      Some highlights of our benefits are:

      • Great work environment with growth opportunity
      • Subsidized downtown parking (for inoffice positions)
      • Competitive compensation
      • Generous amounts of vacation and sick time
      • Closed on major holidays
      • 401(k) with company match
      • A fantastic healthcare package
      • Tuition reimbursement after 6 months of employment
      • Service recognition after 5 years of employment

      • In accordance with pay transparency laws and regulations, the following good faith compensation range estimate is being provided. The salary range for this position is $80,000 $95,000 per year. Final compensation will be based on candidate qualifications, geographic location, and other considerations permitted by law.