Key Facts

Remote From:

Full time

English

Hard Skills

Return-to-Work Management Care Management Medical Record Management Care Coordination Organisational Policies Drug Utilization Review Case Assessment Clinical Assessments Metadata Standards Provider Network Management +5 more

Other Skills

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Quality Assurance
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Computer Literacy
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Client Confidentiality
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Communication
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Time Management
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Organizational Skills
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Detail Oriented
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Prioritization
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Social Skills

Roles & Responsibilities

Excellent communication and organizational skills interfacing with clients, claimants, and staff.
Ability to work independently and set priorities.
Knowledge of HIPAA and PHI regulations and maintaining confidentiality.
Experience with telephonic case management and coordination of care in a workers' compensation/healthcare environment.

Requirements:

Provide telephonic outreach for assessment, follow-up, and coordination of care to address return-to-work goals.
Conduct and document initial assessment with the injured worker, employer, and provider and maintain regular contact to formulate a clinical case plan.
Review case records, analyze data, assess medical status, and coordinate contact with provider, claimant, RTW contact, and claims examiner to deliver proactive case management.
Facilitate timely return-to-work by coordinating RTW with the claimant, employer, and physicians, and telephonically monitor medical appointments to address treatment plans and potential issues.

TRISTAR Insurance Group

Insurance

About TRISTAR Insurance Group

TRISTAR began as an insurance program manager and medical malpractice claims administrator in 1987. Workers compensation claims management services were added in our offerings in 1989, and the Company was renamed TRISTAR Risk Management in 1995. As managed care and benefits administration services were added to our offerings, the organization grew into TRISTAR. We are the largest privately held third party claims administrator in United States. We empower more than 1,000+ professionals in offices throughout the United States, focusing business operations in three divisions: property casualty claims management, benefits administration, and managed care services. We are true to our values of RESPECT, INTEGRITY, TRUST, and EXCELLENCE, making the right choices both financially and ethically. At TRISTAR we strive to create an environment of respect, wherein all of us are encouraged to learn and to grow, to provide exceptional service to our clients and in turn to enjoy the satisfaction that comes from a job well done. We believe that to provide real service, we must contribute something which cannot be bought or measured with money: sincerity and integrity. At TRISTAR, you help create a world in which together we "transform risk into opportunity".

Company type: SME

Industry: Insurance

Founded: 2018

Company size: 501 - 1000

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Job description

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

Responsible for coordination of contact with provider, claimant, RTW contact, and claims examiner
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
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
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
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