TCM/FCM Hybrid Nurse Case Manager

Rising Medical Solutions

About The Position

The Nurse Case Manager coordinates care for injured or disabled individuals, including high-risk, high-cost, and complex cases. Using professional nursing judgment and case management principles, the role assesses needs, facilitates appropriate treatment, monitors progress, supports functional recovery and return-to-work goals, and promotes quality, cost-effective outcomes. The position collaborates with clients, patients, employers, providers, attorneys, and other stakeholders. The role maintains a mixed caseload of field and/or telephonic case management files, typically 30–40 cases. It requires accurate and timely clinical documentation, tracking and reporting case activity, responding to case-status inquiries, and entering information in Rising and client claims systems where applicable. The Nurse Case Manager also supports quality and compliance requirements, assists with URAC accreditation activities, and provides nursing insight to internal teams as requested. This is a full-time position scheduled from 9:00 a.m. to 5:30 p.m. CST, with flexibility to adjust time based on jurisdiction. The posting describes a relaxed, upbeat work environment.

Requirements

Current, active, unrestricted RN license in the primary residence state.
Professional nursing degree (ASN or BSN).
3–5 years of case management experience, including 1–2 years of specific workers’ compensation nurse case management experience.
Experience with workers’ compensation, liability, or disability claims.
Strong computer skills, including Microsoft Outlook, Excel, Word, and related Microsoft Suite applications.
Ability to maintain confidentiality of all information, policies, and procedures.
Ability to set priorities and work autonomously as well as as part of a team.
Demonstrated sensitivity to culturally diverse people and situations.
Well-developed time management, organization, and prioritization skills.
Knowledge of utilization management, case management, and health care provided throughout the health continuum.
Excellent oral and written communication skills, with a strong customer-service focus.
Ability to gather data, compile information, and prepare summary reports.
Strong interpersonal and conflict-resolution skills.
Experience in a fast-paced, multifaceted environment.
Demonstrated persistence and attention to detail.
Ability to stay calm during stressful situations.

Nice To Haves

RN license in a compact state.
California RN license.
Medical bill review experience with workers’ compensation, auto, or health insurance carriers.
CCM and/or other insurance or workers’ compensation certifications.

Responsibilities

Maintain a mixed caseload of field and/or telephonic case management files, typically 30–40 cases.
Establish collaborative relationships and serve as an intermediary among clients, injured or disabled individuals, employers, providers, attorneys, and other involved parties.
Manage high-risk, high-cost, and complex cases by assessing clinical, functional, psychosocial, and vocational needs.
Assess, coordinate, implement, monitor, and evaluate individualized care plans using principles of medical necessity, appropriateness of care, case management, and managed care.
Promote quality, cost-effective care across the health care continuum to support optimal function and safe, timely return to work when appropriate.
Assess injury severity, extent of disability, treatment plans, functional abilities, and physical job requirements to develop return-to-work strategies and help manage future medical exposure.
Track and report case management activity, and maintain organized, timely, accurate clinical documentation of interactions, interventions, barriers, outcomes, and communications.
Respond to written and telephonic inquiries regarding case status and document relevant case information in Rising systems and client claims systems, when applicable.
Adhere to applicable state, national, accreditation, departmental, and client-specific quality standards, guidelines, policies, procedures, and reporting requirements.
Escalate potential clinical, operational, service, or compliance concerns to the appropriate supervisor.
Assist with URAC accreditation activities and maintenance of related policies and procedures.
Provide professional nursing insight to Rising Medical Bill Analysis and other internal teams, as requested.