Job: Nurse Case Manager

The Nurse Case Manager is responsible for the analysis and management of medical issues and treatment in workers compensation claims. This position will review to authorize, partially authorize or delay treatment in accordance the ACOEM (American College of Occupational and Environmental Medicine) guidelines. The Nurse Case Manager will work closely with the Medical Director to facilitate prompt medically necessary and appropriate care to injured workers. The Nurse Case Manager will conduct the medical management of claims in the utmost of good faith in compliance with the rules, regulations and statutes of the WCAB and State of California. The Nurse Case Manager is expected to function with a degree of competency. The use of sound judgment coupled with consistent results is expected.


RESPONSIBILITES:

Identifying and selecting appropriate provider and facilities, while assuring timely access to services.

Analyzes treatment plans.

Authorizes treatment in accordance with the ACOEM guidelines.

Issues all authorizations and advises the bill review company.

Refers all information relative to the request that falls outside the ACOEM guidelines to the Medical Director for review.

Issues all delays and advises the bill review company.

Documents the claim file of all activities taken in conjunction with requests for authorization.

Collaborate with the claims examiner to manage the medical throughout the life of the claim

Works with the examiner to manage medical throughout the life of the claim.

Assigns and supervises Field Case Managers when appropriate.

Coordinates ancillary services.

Assists in RTW.

Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims.

Frequently communicates with all appropriate parties involved with the claim.

Refers cases as appropriate to management.

Maintains professional client relationships.


KEY ACCOUNTABILITES:
Utilization Review
Referral within the network for PTP and all services.
Medical Management
Medical and Disability Management

(This is not a management position.)

5+ years claims management experience.

In depth knowledge of appropriate medical principles.

Understanding of laws for workers' compensation.

Demonstrate an understanding of the relationship of medical condition to AOE/COE.

Knowledge of ACOEM guidelines.

Knowledge of ICD-9 and CPT codes.

Strong written and verbal communication skills.

Strong organizational skills.

Strong negotiation skills

Strong analytical and interpretive skills.

PC literate.

Active RN license.

Baccalaureate degree from an accredited college or university preferred.

Professional designation required.