Telephonic Nurse Case Manager (Remote)

Department: Claims Administration & Adjusting

Employment Type: Permanent - Full Time

Location: Home United States

Reporting To: Medical MGMT Program Manager

Compensation: $78,000 - $83,000 / year

Description

Key Responsibilities

• Provide telephonic case-management in a Workers’ Compensation environment.
• Focus on medical appropriateness of care to injured worker with cost savings by coordination and utilization of all services, ensuring that as soon as medically feasible, return-to-work status is achieved, along with increase in productivity. 
• Facilitate communication between the employee, the employee representative, employer, employer representative, insurer, health care provider, the medical services organization and when authorized, any qualified rehabilitation consultant, to achieve the goals 
• Clinically evaluate the recovery needs of an injured employee after the initial contact assessment. Incorporate into the initial plan information obtained from the employer and provider.
• Identify barriers to recovery and formulates an action plan to overcome these barriers.
• Provide ongoing assessment of health and medical records. 
• Monitor and audit health provider ensuring licensure and appropriate care.
• Monitor vendor performance, ensuring quality service.
• Develop case management care plan, tracks and modifies appropriately.
• Appropriately document all data received from interviews, contacts and medical records in the computerized system.
• Address the return-to-work capability with the injured worker and provider at each medical evaluation, document appropriately in computerized system, obtain a job description from the employer and presents to the provider if necessary. Verify disability against approved guidelines, questioning variances.
• Manage the file adhering to treatment guidelines and utilization criteria as determined by the state-mandated guidelines, proprietary and nationally published protocols, as well as account requirements, assuring smooth delivery of services to injured workers or third party claimants.
• Create, edit and/or revise correspondence. 
• Evaluate treatment plans and documents outcomes.
• Track protocol management for appropriate utilization and delivery of medical services.
• Outcomes will be evidenced by patient satisfaction, appropriate delivery and quality of care and timely recovery per evidenced based criteria and clinical guidelines. Return-to-work outcomes and length of disability outcomes are calculated and monitored according to criteria as published in the Official Disability Guidelines.
• Manage the file pro-actively, utilizing all appropriate case management tools. 
• Develop alternative treatment plans when necessary.
• Demonstrate the ability to accommodate changes on the case-management process for delivery of a more refined and efficient system.
• Identify the need for utilization review procedures to claims, such as triggers that might indicate a potential barrier to recovery. UR tools include physician advisor review, pre-certification, pre-authorization, concurrent review and retrospective review of bills and reports. Communicate the findings determined in utilizing these tools and document appropriately.
• Anticipate health needs during case-management process and educate patient and family appropriately. Encourages the injured worker to participate in the recovery plan.
• Review medical bills for appropriateness and forward bills to Bill Review/Cost Containment Organization for adjudication.
• Maintain patient privacy by ensuring that all medical records, case specific information and provider specific information are kept in a confidential manner, in accordance with state and federal laws and regulations.
• Serve as a patient advocate adhering to all legal, ethical and accreditation/regulatory standards.
• Serve on appropriate committees such as Grievance, Quality Assurance and others as directed. 
• May negotiate fees with providers or channel cases to other vendors as appropriate.
• Maintains contracted State of Florida performance standards for case management.
• May train claims staff on the identification of medical case management opportunities.
• May provide leadership of lower graded staff in the department.

Skills, knowledge & expertise

• RN with a minimum of three years clinical experience (medical-surgical, orthopedic, neurological, ICCU, industrial or occupational).
• At least one year’s experience handling Florida Workers’ Compensation case management (contractual requirement).
• Proof of current State Licensure
• Bilingual – fluent English/Spanish helpful.
• Case-management experience mandatory – 1 year Florida Workers’ Compensation.
• Maintains knowledge of current trends, standards and law changes.
• Must be self directed and able to work independently.
• Ability to effectively operate a personal computer and related claims and business software. 
• Good communication skills, both oral and written. Team player. Good attendance. Good customer service skills.

Equal Employment Opportunity & Legal Notices

• Medical, dental, and vision plans to support your health and that of your family
• A 401(k) plan with employer matching
• Time‑off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non‑exempt employees
• Paid holidays
• Life insurance and short‑term and long‑term disability coverage

• Maintain regular and dependable attendance.
• Be available and able to perform job responsibilities during established work hours.