[Hiring] Telephonic Medical Case Manager @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, including:
  • Assessing, planning, implementing, and coordinating care.
  • Conducting and documenting initial assessment with the injured worker, employer, and provider.
  • Maintaining regular contact with all parties involved to facilitate communication and 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 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, 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.

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.

Qualifications

• Three or more years of diverse clinical experience in caring for acutely ill patients with multiple disease conditions.
• Three or more years of Managed Care and/or Worker's Compensation experience.
• Knowledge of utilization management, quality improvement, discharge planning, and cost management.
• Background in state worker's compensation law and practices desirable.
• Ability to solve practical problems and deal with a variety of variables.
• Possess planning, organizing, conflict resolution, and negotiating skills.
• Excellent interpersonal skills and excellent organizational skills.
• Proficient with Microsoft Office applications including Word, Excel, and PowerPoint.

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 RN license required.
• CCM, CPDM, COHN or CDMS certification preferred.