Senior Nurse Case Manager - Chicago, Illinois

Blue Cross Blue Shield of Michigan•Lansing, IL

8d•Hybrid

About The Position

The Senior Nurse Case Manager (SNCM) supports Claims Department management and the claims team in strategic initiatives and annual claims goals. The role applies medical knowledge to review complex workers’ compensation claims, assess the causal relationship between symptoms and reported work injuries, evaluate the medical necessity and reasonableness of treatment, facilitate return to work, and propose alternative care arrangements. The SNCM also helps develop medical cost-containment programs and projects and leads their implementation and ongoing support. The role may perform its essential functions telephonically or as a Field Nurse Case Manager, coordinating or providing in-person care. The field/hybrid focus involves managing medical care and facilitating return to work through on-site, face-to-face interaction with injured employees, providers, and employers to support appropriate, timely care and recovery. The position requires clinical and jurisdictional knowledge, strong communication, negotiation, decision-making, organization, time-management, problem-solving, and conflict-resolution skills. It involves collaborating with internal and external customers, working independently and as part of a team, training or mentoring less-experienced nurse case managers, and assisting with reports, quality evaluations, and customer presentations. Work is performed in an office or remotely; Field SNCMs travel for on-site interactions. Compensation is estimated at $73,600 to $123,200, with actual compensation depending on factors including skills, experience, location, and market considerations.

Requirements

Active, unrestricted Registered Nurse license.
Five years of progressive responsibility in injury case management, such as workers’ compensation, group health, or auto.
Three years of active patient or clinical experience as a registered nurse.
Knowledge of clinical care and jurisdictional requirements.
Strong negotiation and decision-making skills; excellent oral and written communication, customer service, report preparation, and human-relations skills.
Proficiency in Microsoft Windows Suite.
Ability to work independently and within a team, with strong attention to detail and analytical skills.
Demonstrated leadership abilities and ability to train others.
Ability to establish and maintain effective working relationships with internal and external customers.
Ability to research, plan, develop, and implement corporate projects independently, and manage resources, budgets, issues, and risks.
Working knowledge of workers’ compensation laws.
Ability to exercise sound judgment in workers’ compensation claims management and to read, analyze, and interpret technical, legal, and financial information and procedure manuals.
Ability to make competent, independent decisions and maintain confidentiality where appropriate.
For Field Nurse Case Managers, an unrestricted and valid driver’s license.

Nice To Haves

Bachelor of Science in Nursing (BSN).
Three years of workers’ compensation case management, rehabilitation, insurance, or occupational health experience.
Field Case Manager experience.

Responsibilities

Oversee new assignments and make timely initial contact with all parties.
Review patient clinical status and history to determine whether symptoms are causally related to reported work injuries.
Complete RN templates and documentation, including pertinent medical history, exposure analysis, anticipated treatment and treatment duration, disability duration, and anticipated permanency.
Coordinate with employers to arrange early return to work or alternative duties based on provider reports of employees’ abilities.
Oversee external nurse case management and external RN task assignments; document assignment strategy and anticipated claim cost benefit, and establish a plan of action and completion timeframe with external nurse case managers.
Apply medical knowledge in contacts with physicians, therapists, and other providers, particularly in cases involving prolonged treatment.
Determine the medical necessity and reasonableness of proposed and ongoing treatment, including inpatient or outpatient hospitalization for lost-time cases.
Research cases, including contacting or meeting with employees, employers, physicians, medical staff, and medical consultants as necessary.
Refer cases that do not meet medical criteria to the medical director, designated consultant, or independent physician, with supporting documentation.
Prepare correspondence to research and resolve case disputes and inquiries; contact providers and involve claims representatives as needed.
Communicate final decisions and their subsequent ramifications to claim representatives.
Medically manage claims across multiple jurisdictions and close assignments within internal performance standards.
Train and mentor less-experienced nurse case managers.
Prepare professional presentations for prospective customers.
Assist the manager with monthly nurse case management outcomes and reports, and with quality assessment evaluations when needed.
For field assignments, travel and interact face-to-face with injured workers, providers, and employers to coordinate care and facilitate return to work.