Job Details

Level: Experienced

Job Location: Involuntary Remote TMC - Remote, SC

Position Type: Full Time

Education Level: Bachelor's Degree

Salary Range: $85000.00 - $90000.00 Salary/year

Job Shift: Day

Job Category: Insurance

Please make sure to complete all the questions in the application and continue through to the end in order to sign and submit it.

SUMMARY

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 to include assessing, planning, implementing, and coordinating care.
• Conducts and documents initial assessment with the injured worker, employer, and provider and maintains 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.
• Reviews case records and reports, collects and analyzes data, evaluates client's medical status, and defines needs and problems in order 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.
• Maintains contact and communicates updated activity with all parties involved with the case.
• Telephonically monitor medical appointments of the injured worker to address RTW, current treatment plan and, 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 HIPPA and PHI.
• Other job duties as assigned.

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.

Experience

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

• 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 Workers' Compensation experience.
• Knowledge of utilization management, quality improvement, discharge planning, and cost management.
• Background in state workers' 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.
• Bilingual a plus.
• Preferred multi-state experience, including California.

POSITION Qualifications

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.

Benefits

Here are some of the benefits you can enjoy in this role: Medical, Dental, Vision Insurance. Life and Disability Insurance. 401(k) Plan Paid Holidays Paid Time Off. Referral bonus.

Mental and Physical Requirements

MENTAL EFFORT

• Reasoning development: Follow one- or two-step instructions; routine, repetitive task. Carry out detailed but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. Solve practical problems; variety of variables with limited standardization; interpret instructions. Logical or scientific thinking to solve problems; several abstract and concrete variables. Wide range of intellectual and practical problems; comprehend most obscure concepts.
• Mathematical development: Simple addition and subtraction; copying figures, counting, and recording. Add, subtract, multiply, and divide whole numbers. Arithmetic calculations involving fractions, decimals, and percentages. Arithmetic, algebraic, and geometric calculations. Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination. Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.
• Language development: Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing. Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction. Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants. Ability to compose original correspondence, follow technical manuals, and have increased contact with people. Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

PHYSICAL EFFORT

• Physical activity required to perform the job: Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
• Light work: Exerting up to 20 pounds of force occasionally; Exerting up to 10 pounds frequently; Exerting a negligible amount of force constantly to move objects.
• Medium work: Exerting up to 50 pounds of force occasionally; Exerting up to 20 pounds of force frequently; Exerting up to 10 pounds of force constantly to move objects.
• Heavy work: Exerting up to 100 pounds of force occasionally; Exerting up to 50 pounds of force frequently; Exerting up to 20 pounds of force constantly to move objects.
• Very heavy work: Exerting in excess of 100 pounds of force occasionally; Exerting in excess of 50 pounds of force constantly to move objects; Exerting in excess of 20 pounds of force constantly to move objects.

Visual requirements necessary to perform the job

• Far vision: clarity of vision at 20 feet or more.
• Near vision: clarity of vision at 20 inches or less.
• Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet.
• Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are.
• Color vision: ability to identify and distinguish colors.
• Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point.

WORKING CONDITIONS

Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure.

Signatures

This job description has been approved by all levels of management: Human Resources: ___________________ The employee's signature below constitutes the employee's understanding of the mental and physical requirements, essential functions, and duties of the position. Employee____________________________ Date____________________