Medical Case Manager, Telephonic Case Management

Tristar Insurance•Summerville, SC

1d•$85,000 - $90,000•Remote

About The Position

The Medical Case Manager provides telephonic case management in a workers’ compensation environment. The role coordinates resources and cost-effective options on a case-by-case basis to support quality, individualized treatment goals and return-to-work placement. The position requires strong communication and organizational skills, the ability to work independently, and effective prioritization. It is a full-time, remote position with a day shift.

Requirements

Current, unrestricted RN license.
Three or more years of diverse clinical experience 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.
Ability to solve practical problems and work with a variety of variables.
Planning, organizing, conflict-resolution, and negotiation skills.
Excellent interpersonal, communication, and organizational skills.
Proficiency with Microsoft Office applications, including Word, Excel, and PowerPoint.
Ability to work independently and set priorities.

Nice To Haves

Diploma, associate degree, or bachelor’s degree in nursing; a master’s degree or higher in nursing, health, or human services, or equivalent related experience is preferred.
CCM, CPDM, COHN, or CDMS certification preferred.
Knowledge of state workers’ compensation law and practices desirable.
Bilingual ability is a plus.
Preferred multistate experience, including California.

Responsibilities

Provide telephonic outreach for assessment and follow-up, including assessing, planning, implementing, and coordinating care and case communications.
Conduct and document initial assessments with the injured worker, employer, and provider; maintain regular contact with involved parties to facilitate communication and develop a clinical case plan.
Coordinate contact among providers, claimants, return-to-work contacts, and claims examiners.
Review case records and reports, collect and analyze data, evaluate medical status, identify needs and problems, and provide proactive case management.
Assess medical records for appropriateness of treatment and level of care; refer cases to the Medical Director within established timeframes when appropriate.
Coordinate return-to-work planning and facilitate a timely return-to-work date with the claimant, employer, and physicians.
Maintain contact with parties involved in the case and communicate updates on case activity.
Telephonically monitor injured workers’ medical appointments to address return to work and the current treatment plan, identify potential issues, and promote positive treatment outcomes.
Negotiate treatment plans with treating physicians.
Meet administrative requirements, including productivity, time management, and Quality Assurance standards.
Meet minimum billing and template documentation standards in accordance with URAC standards and company policies and procedures.
Report billing hours in accordance with case activity and billing practices.
Maintain confidentiality and comply with requirements relating to HIPAA and protected health information.
Perform other duties as assigned.