Telephonic Medical Case Management (Workers' compensation)

**POSITION SUMMARY:** 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. **ESSENTIAL DUTIES AND RESPONSIBILITIES:** Possess excellent communication and organizational skills to interface with the client, claimants and staff. Work well independently and set priorities. **Primary responsibilities include:** - Provide telephonic outreach for assessment, and follow up for case communication and coordination to include assessing, planning, implementing, coordinating of care - Conducts and documents 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 - Reviews case records and reports, collects and analyzes data, evaluates client's medical status and defines 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 - Maintains contact and communicates 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 **Additional Functions and Responsibilities** - Demonstrates 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 - Reporting 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 **Education** **:** - 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 - Current, unrestricted Registered Nurse (RN), Licensed Practical Nurse (LPN) and or Certified Case Manager (CCM) license required - CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred **Experience** **:** To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability 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 **EQUIPMENT OPERATED/USED:** Essential Equipment: Desk, Telephone/Fax, Computer Keyboard, Mouse, System Applications Essential Tools: Pens, pencil, computer, Keyboard Essential Vehicles: N/A **SPECIAL EQUIPMENT OR CLOTHING:** Professional attire adhering to the Company Dress Code | **MENTAL AND PHYSICAL REQUIREMENTS** | | --- | | **1. MENTAL EFFORT** a. Reasoning development: Follow one- or two-step instructions;…