Job Title Medical Case Manager

Summary:

The Medical Case Manager provides comprehensive quality telephonic case management to proactively drive a medically appropriate return to work through engagement with the injured employee, provider, and employer. The Medical Case Manager is empathetic, informative, and collaborative. This position coordinates medical resources for our injured employees and partners with the Client Claims Adjuster team to develop a personalized holistic approach for each claim. Maintains a solid understanding of Client’s mission, vision, and values. Upholds the standards of the Client organization.

Roles and Responsibilities:

• PH Registered nurses to review workers compensation claims with serious injury and that need surgery/lengthy treatments, create a return-to-work plan, work with various stakeholders (medical providers, injured worker, employer, attorney) to track the treatment plan and help bring the injured worker back to work.

• Nurses have continuous communication with injured workers and as a single point of contact for the injured workers

• Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered.

• Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary

• Responsible for accurate comprehensive documentation of case management activities in case management system.

• Uses clinical/nursing skills to help coordinate the individual’s treatment program while maximizing quality and cost-effectiveness of care including direction of care to preferred provider networks where applicable.

• Addresses need for job description and appropriately discusses with employer, injured employee and/or provider. Works with employers on modifications to job duties based on medical limitations and the employee’s functional assessment.

• Responsible for helping to ensure injured employees receive appropriate level and intensity of care through use of medical and disability duration guidelines, directly related to the compensable injury and/or assist adjusters in managing medical treatment to drive resolution.

• Communicates effectively with claims adjuster, client, vendor, supervisor, and other parties as needed to coordinate appropriate medical care and return to work.

• Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client’s situation to include psychosocial needs, cultural implications, and support systems in place.

• Objectively and critically assesses all information related to the current treatment plan to identify barriers, clarify, or determine realistic goals and objectives, and seek potential alternatives.

• Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome.

• Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim.

• Engage specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director).

• Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves.

• Keeps current with market trends and demands.

• Performs other functionally related duties as assigned.

Required Qualifications:

• Bachelor’s degree in nursing (BSN)

• Active unrestricted RN license that can be validated thru PRC website

• 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department

• Written and verbal fluency in English

• Candidate should be willing to work onsite (BGC)

• Candidate should be willing to work in US operation hours

Preferred:

• Proficiency in all Microsoft Office products including Project, Word, Excel, PowerPoint, Visio, and SharePoint

• Knowledge of workers’ compensation laws and regulations, behavioral health, case management practice, URAC standards, ODG, Utilization review, pharmaceuticals to treat pain, pain management process, drug rehabilitation, state workers compensation guidelines, periods of disability, and treatment needed

• Leadership/management/motivational skills as well as analytic and strong organizational skills

• Ability to work in a team environment and to meet or exceed Performance Competencies