Medical Case Manager, Telephonic Case Management

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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, and 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

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

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 Workers' Compensation experience
• Knowledge of utilization management, quality improvement, discharge planning, and cost management
• Background in state workers' 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 PowerPoint.

• Bilingual a plus

• Preferred multi-state experience, including California. POSITION