Triage Telephonic Nurse Case Manager

Department: Claims Administration & Adjusting

Employment Type: Permanent - Full Time

Location: Home United States

Reporting To: Shaunna Jones

Compensation: $66,000 - $67,000 / year

Description

Key Responsibilities

• Provide telephonic triage case management services at the onset of workers' compensation claims.
• Conduct comprehensive clinical assessments of injured employees at the time of injury and determine appropriate levels of care.
• Complete initial evaluations and required three-point contacts in accordance with state requirements and established protocols.
• Assess medical appropriateness of treatment and support timely access to care.
• Develop and implement initial case management care plans based on assessment findings.
• Coordinate communication among injured workers, employers, providers, claims professionals, and other stakeholders.
• Identify potential barriers to recovery and document findings for future case planning.
• Evaluate return-to-work capabilities and facilitate modified duty discussions when appropriate.
• Monitor treatment plans for compliance with state guidelines, evidence-based protocols, and client-specific requirements.
• Identify potential causation concerns and communicate findings to appropriate parties.
• Accurately document all assessments, contacts, medical information, and case activities within the claims management system.
• Serve as a patient advocate while maintaining compliance with all legal, ethical, and regulatory requirements.
• Support utilization management efforts through coordination of appropriate medical services and resources.
• Participate in quality assurance initiatives and departmental projects as assigned.
• Provide education and support to injured workers and their families throughout the recovery process.
• Assist in training claims personnel regarding medical case management opportunities and clinical considerations.
• Serve as a resource and mentor to team members as needed.

Skills, knowledge & expertise

• Current unrestricted Registered Nurse (RN) license.
• Minimum of 3 years of clinical nursing experience in one or more of the following: 
  • Medical-Surgical
  • Orthopedics
  • Neurology
  • Critical Care/ICU
  • Occupational Health
  • Industrial Nursing
• Strong clinical assessment and critical thinking skills.
• Excellent verbal and written communication skills.
• Ability to work independently and make sound clinical decisions.
• Proficiency with Microsoft Office Suite and healthcare or claims-related systems.
• Ability to manage multiple priorities in a fast-paced environment while maintaining attention to detail.

• Previous Workers' Compensation case management experience.
• Telephonic case management experience.
• CCM (Certified Case Manager) designation or progress toward certification.
• Experience in utilization review or managed care environments.
• Familiarity with state workers' compensation regulations and treatment guidelines.
• Experience working in a call center or high-volume intake environment.
• Bilingual skills are a plus.

• Clinical Assessment & Triage
• Workers' Compensation Case Management
• Return-to-Work Coordination
• Medical Documentation Review
• Care Coordination
• Customer Service Excellence
• Critical Thinking & Problem Solving
• Communication & Relationship Building
• Time Management & Organization
• Patient Advocacy
• Regulatory Compliance
• Independent Decision Making

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