[Hiring] Telephonic Medical Case Management @Tristar Insurance

Role Description

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.
• Provide telephonic outreach for assessment and follow-up for case communication and coordination to include assessing, planning, implementing, and coordinating 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.

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 HIPAA and PHI.
• Other job duties as assigned.

Qualifications

• 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

• 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 PowerPoint.

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

• Mental Effort:
  • Follow one- or two-step instructions; routine, repetitive task.
  • Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables.
  • Follow written, verbal, or diagrammatic instructions; several concrete variables.
  • Solve practical problems; variety of variables with limited standardization; interpret instructions.
  • Logical or scientific thinking to solve problems; several abstract and concrete variables.
  • Wide range of intellectual and practical problems; comprehend most obscure concepts.
• Mathematical Development:
  • Simple addition and subtraction; copying figures, counting, and recording.
  • Add, subtract, multiply, and divide whole numbers.
  • Arithmetic calculations involving fractions, decimals, and percentages.
  • Arithmetic, algebraic, and geometric calculations.
  • Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.
  • Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.
• Language Development:
  • Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.
  • Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.
  • Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.
  • Ability to compose original correspondence, follow technical manuals, and have increased contact with people.
  • Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

Physical Effort

• Physical activity required to perform the job:
  • Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time.
  • Light work: Exerting up to 20 pounds of force occasionally; exerting up to 10 pounds frequently; exerting a negligible amount of force constantly to move objects.
• Visual Requirements necessary to perform the job:
  • Far vision: clarity of vision at 20 feet or more.
  • Near vision: clarity of vision at 20 inches or less.
  • Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet.
  • Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are.
  • Color vision: ability to identify and distinguish colors.
  • Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point.