Telephonic Medical Case Manager (Workers' compensation)

Tristar Insurance•Summerville, SC

3d•Remote

About The Position

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.

Requirements

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 Worker's Compensation experience
Knowledge of utilization management, quality improvement, discharge planning, and cost management
Background in state worker's 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 Power Point
Current, unrestricted RN license required

Nice To Haves

Master's level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred
CCM, CPDM, COHN or CDMS certification preferred

Responsibilities

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
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