Telephonic Nurse Case Manager: California RN License (Remote)

Department: Claims Administration & Adjusting

Employment Type: Permanent - Full Time

Location: Home United States

Reporting To: Nurse Case Manager Supervisor

Compensation: $83,000 - $88,000 / 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 managed care organization and when authorized, any qualified rehabilitation consultant, to achieve the goals ensuring excellent customer relationships and quality customer service.
• Build and maintain excellent rapport with client contacts to ensure retention; perform in manner to meet/exceed client expectations, following policy and procedure.
• 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.
• Ensure appropriate, progressive education is provided to the injured employee in a consistent manner, and documented in the system.
• Identify barriers to recovery and formulates an action plan to overcome these barriers.
• Provide ongoing assessment of health and medical records. 
• Monitor and audit provider and vendor performance and care.
• Develop case management care plan, track and modify 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.
• 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.
• 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 medical director 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.
• 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.
• May train claims staff on the identification of medical case management opportunities.
• May provide leadership of lower graded staff in the department.
• Perform other duties as needed.

Skills, knowledge & expertise

• RN with a minimum of three years clinical experience (medical-surgical, orthopedic, neurological, ICCU, industrial, ER or occupational).
• Workers’ Compensation experience 3+ years
• Proof of current State Licensure, compact license preferred 
• California RN, or ability to obtain California endorsement within 6 months 
• Case-management experience desired – Workers’ Comp preferred.
• 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.