Senior Nurse Case Manager, Knoxville, TN

Blue Cross Blue Shield of Michigan•Lansing, TN

About The Position

The Senior Nurse Case Manager (SNCM) works within the Claims Department to support management and the claims team in advancing strategic initiatives and achieving annual claims goals. The role applies medical knowledge to complex workers’ compensation claims, including evaluating the causal relationship between symptoms and reported work injuries, assessing the medical necessity and reasonableness of treatment, facilitating return to work, and proposing 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 providing in-person care and coordination. The Field SNCM manages medical care and facilitates return to work for injured employees. This hybrid focus involves on-site, face-to-face interaction with injured workers, providers, and employers to coordinate appropriate and timely care that supports recovery and return to work. The position may also train or mentor less experienced nurse case managers, prepare presentations for prospective customers, and assist with monthly outcomes reporting and quality assessments. Work is performed in an office setting or remotely, with no unusual hazards. Field SNCMs travel for required on-site interactions. The stated compensation estimate is $73,600 to $123,200; actual compensation depends on factors including internal equity, skills, experience, geographic location, and market conditions.

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 as part of a team.
Attention to detail and analytical skills.
Demonstrated leadership abilities and the ability to build teams, motivate employees, and work collaboratively to empower others.
Ability to independently research, plan, develop, and implement corporate projects.
Ability to manage resources, budgets, issues, and risks for successful project completion.
Ability to train others and maintain effective working relationships with internal and external customers.
Strong working knowledge of workers’ compensation laws.
Ability to exercise good judgment in evaluating and determining appropriate actions in workers’ compensation claims management.
Ability to read, analyze, and interpret technical, legal, and financial information and procedure manuals.
Ability to make competent independent decisions and maintain confidentiality where appropriate.
Field Nurse Case Managers must have an unrestricted, valid driver’s license.

Nice To Haves

Bachelor’s degree 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 patients’ clinical status and history to assess whether symptoms are causally related to reported work injuries.
Complete RN templates and documentation, including medical history, exposure analysis, anticipated treatment and treatment duration, disability duration, and anticipated permanency.
Coordinate with employers to facilitate early return to work or alternative duty based on providers’ 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 parties, including review of cases involving prolonged treatment.
Determine the medical necessity and reasonableness of proposed and ongoing treatment and inpatient or outpatient hospitalization for lost-time cases.
Research cases, contacting or meeting with employees, employers, physicians, medical staff, and medical consultants as needed.
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, contacting providers and involving claims representatives as required.
Communicate final decisions and their implications to claims representatives.
Medically manage claims in multiple jurisdictions and close assignments within internal performance standards.
Train or mentor less experienced nurse case managers.
Prepare professional presentations for prospective customers.
Assist the manager with monthly nurse case management outcomes, reports, and quality assessment evaluations as needed.
For Field SNCM work, manage medical care and facilitate return to work through on-site, face-to-face interaction with injured workers, providers, and employers.