Senior Nurse Case Manager- Brighton, Michigan

Blue Cross Blue Shield of Michigan•Lansing, MI

5d•Hybrid

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, assessing the causal relationship between symptoms and reported work injuries, the necessity and reasonableness of treatment, return-to-work options, and alternative care arrangements. The SNCM also helps develop medical cost-containment programs and projects and leads their implementation and ongoing support. The position may perform its essential functions telephonically or as a Field Nurse Case Manager, providing in-person care and coordination. The field focus involves managing medical care and facilitating injured employees’ return to work through on-site, face-to-face interaction with injured workers, providers, and employers to support appropriate, timely care and recovery. The role also provides oversight and guidance to external nurse case managers, mentors less-experienced nurse case managers, supports quality and outcomes reporting, and may prepare presentations for prospective customers. Work is performed in an office setting or remotely without unusual hazards. The field role is hybrid and requires travel for in-person interactions. The stated compensation estimate is $73,600 to $123,200; actual compensation depends on factors including internal equity, skills, experience, location, and market conditions. The employer is an Equal Opportunity Employer and states that employment is at will.

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, with attention to detail and analytical skills.
Demonstrated leadership abilities and the ability to collaborate with, empower, and maintain effective working relationships with internal and external customers.
Ability to research, plan, develop, and implement corporate projects independently, and to manage project resources, budgets, issues, and risks.
Ability to train others.
Strong working knowledge of workers’ compensation laws.
Ability to exercise sound 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.
For Field Nurse Case Managers, an unrestricted and valid driver’s license is required.

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 relevant medical history, exposure analysis, anticipated treatment and treatment duration, disability duration, and anticipated permanency.
Coordinate with employers on 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 professionals, particularly on cases involving prolonged treatment.
Determine the necessity and reasonableness of proposed and ongoing treatment and inpatient or outpatient hospitalization for lost-time cases.
Research cases by contacting or meeting with employees, employers, physicians, medical staff, and medical consultants as needed.
Refer workers’ compensation 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 required.
Communicate final decisions and their subsequent ramifications to claims representatives.
Medically manage claims across multiple jurisdictions and close assignments within internal performance standards.
Train and mentor nurse case managers with less experience.
Prepare professional presentations for prospective customers.
Assist the manager with monthly nurse case management outcomes and reports, and with monthly quality assessment evaluations as needed.
For the field role, manage medical care and facilitate return to work through in-person interaction with injured workers, providers, and employers.