Telephonic Medical Case Management (Workers' compensation)

Tristar Insurance • SC

139d • $85,000 - $110,000

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. This is a remote position but must live within a 50 miles radius from Fresno, CA. Will be required to attend quarterly or annual meetings.

Requirements

• High School Diploma or GED required.
• Current, unrestricted Registered Nurse (RN), Licensed Practical Nurse (LPN) and or Certified Case Manager (CCM) license required.
• Three or more years of diverse clinical experience in acute care.
• Two or more years of medical case management or managed care experience, Worker’s Compensation background preferred.
• Knowledge of utilization management, quality improvement, discharge planning, and or cost management.
• Ability to solve practical problems and deal with a variety of variables.
• Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
• Excellent interpersonal skills and excellent organizational skills.
• Ability to set priorities and work independently is essential.
• Proficient with Microsoft Office applications including Word, Excel, and Power Point.

Nice To Haves

• Diploma, Associate or Bachelor’s degree in Nursing, Master’s level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred.
• CCM, CMCN, CPHUR, 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 of care.
• Conduct and document initial assessment with the injured worker, employer and provider and maintain regular contact with all parties involved to facilitate communication and to formulate a clinical case plan.
• Responsible for coordination of contact with provider, claimant, RTW contact and claims examiner.
• Review case records and reports, collect and analyze data, evaluate client's medical status and define 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.
• Maintain contact and communicate 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.
• Demonstrate 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.
• Report 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.

Benefits

• Medical, Dental & Vision Insurance
• Life & Disability Insurance
• 401(k) plan
• Paid time off
• Paid holidays
• Referral bonus

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 501-1,000 employees