[Hiring] Telephonic Medical Case Management (Workers' compensation) @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.

• 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.

• 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.

Requirements

• 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.

Benefits

• Professional attire adhering to the Company Dress Code.