Telephonic Nurse Case Manager: California RN License (Remote)

Davies • Home, WV

23h • $83,000 - $88,000 • Remote

About The Position

Davies Claims North America is seeking an experienced Telephonic Nurse Case Manager to manage medical claims and make independent decisions. The role analyzes, evaluates, and coordinates appropriate, timely, cost-effective medical treatment and related health services for injured employees, with the goal of supporting a prompt return to work when medically indicated. The nurse case manager oversees care across the service continuum and conducts ongoing recovery assessments to promote quality care, reduce recovery time, and minimize the effects of injury. Telephonic case management is performed on Workers’ Compensation cases according to established parameters. The position requires a California RN license or the ability to obtain a California endorsement within six months.

The role involves coordinating care and communication among injured workers, employers, insurers, healthcare providers, and other authorized parties; developing, monitoring, and adjusting case-management plans; documenting case activity; applying treatment guidelines and utilization criteria; identifying barriers to recovery; and advocating for patients while complying with applicable legal, ethical, privacy, and regulatory standards. The position is remote and reports to the Nurse Case Manager Supervisor.

Requirements

• Registered Nurse with at least three years of clinical experience in medical-surgical, orthopedic, neurological, ICCU, industrial, emergency room, or occupational settings.
• At least three years of Workers’ Compensation experience.
• Proof of current state licensure; a compact license is preferred.
• California RN license, or ability to obtain California endorsement within six months.
• Ability to work independently and be self-directed.
• Ability to operate a personal computer and related claims and business software.
• Good oral and written communication skills.
• Team-oriented approach, good attendance, and good customer service skills.
• Maintain knowledge of current trends, standards, and changes in law.

Nice To Haves

• Case-management experience; Workers’ Compensation case-management experience is preferred.
• Compact nursing license.

Responsibilities

• Provide telephonic case management in a Workers’ Compensation environment, coordinating services to support medically appropriate care, cost savings, and return to work as soon as medically feasible.
• Facilitate communication among the employee, representatives, employer, insurer, healthcare providers, managed care organization, and other authorized parties.
• Build and maintain client relationships, meet or exceed client expectations, and follow company policies and procedures.
• Assess an injured employee’s recovery needs and incorporate information from the employer and provider into the initial plan.
• Provide and document progressive education for injured employees.
• Identify barriers to recovery and develop action plans to address them.
• Conduct ongoing assessments of health information and medical records.
• Monitor and audit provider and vendor performance and care.
• Develop, track, and appropriately modify case-management care plans.
• Document information from interviews, contacts, and medical records in the computerized system.
• Discuss return-to-work capability with the injured worker and provider at each medical evaluation, document the discussion, and obtain and present job descriptions when necessary.
• Manage files according to state-mandated guidelines, proprietary and nationally published protocols, and account requirements.
• Evaluate treatment plans, document outcomes, and track appropriate utilization and delivery of medical services against clinical guidelines and outcome criteria.
• Manage cases proactively using appropriate case-management tools and develop alternative treatment plans when needed.
• Identify when utilization review procedures may be needed, communicate findings, and document them appropriately.
• Anticipate health needs, educate patients and families, and encourage injured workers to participate in recovery plans.
• Protect confidential medical, case-specific, and provider-specific information in accordance with applicable laws and regulations.
• Advocate for patients while adhering to legal, ethical, accreditation, and regulatory standards.
• Serve on appropriate committees, including Grievance and Quality Assurance committees, as directed.
• Negotiate provider fees or direct cases to other vendors when appropriate.
• Train claims staff to identify medical case-management opportunities when needed.
• Provide leadership to lower-graded department staff when needed.
• Perform other duties as needed.
• Maintain regular and dependable attendance and be available to perform responsibilities during established work hours.

Benefits

• Medical, dental, and vision plans.
• 401(k) plan with employer matching.
• Discretionary Time Off for exempt employees and Paid Time Off for non-exempt employees.
• Paid holidays.
• Life insurance.
• Short-term and long-term disability coverage.
• Paid sick leave, paid family leave, paid parental leave, and other mandated benefits where required by law.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed