The Nurse Case Manager (NCM) is responsible for applying medical knowledge in reviewing workers' compensation claims to assess, evaluate, plan, implement and oversee the treatment appropriateness for occupational injuries based upon evidence based guidelines. The NCM utilizes clinical knowledge to evaluate the medical and disability needs of an injured worker against relevant policies, facilitate coordination of the patient's medical treatment and timely return to work. The NCM engages the claimant and physician(s) in providing proactive medical and disability management, working collaboratively with claim handlers in providing focused claim resolution and return to work driven outcomes. The case management process requires a focus on customer service, skills, knowledge of setting appropriate goals and measuring outcomes to effectively ensure optimal outcomes.
The nurse case manager must be able to demonstrate and be accountable for the standards of practice policies and procedures, quality assurance and the goals of the organization. Also, manage treatment of claimants through the workers' compensation system based on the individual's diagnosis and state workers' compensation regulations.
- Obtains and reviews patient clinical status and history to determine casual nature of patient's symptoms as related to reported work injuries.
- Applies knowledge of age-specific, cultural diversity, psycho/social and developmental issues during the interview process, documentation and intervention with the claimant, their family or significant other.
- Determines the medical necessity/reasonableness of proposed and ongoing treatment as well as inpatient or outpatient hospitalization for each lost-time case.
- Formulates all internal and external correspondence necessary to research and resolve case disputes and case inquiries, contacting providers and involving claims handlers as required. Communicates final decision and subsequent ramifications to claim handlers.
- Presents, discusses and finalizes alternative care and return to work programs with permanency ratings assigned to lost-time cases by medical providers, reinsuring the level of injury and ratings assigned are accurate and consistent with workers' compensation, state, industry and division rating standards and policies, in conjunction with the claim handler.
- As it relates to California: Adhere to California Nurse Practice Act, Case Management Code of Professional Conduct and Employee Code of Ethical Conduct.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. EMPLOYMENT QUALIFICATIONS
Registered Nurse license active and unrestricted required. Bachelor's degree in Nursing (BSN) preferred. Continuous learning required, as defined by the Company's learning philosophy. Certification or progress toward certification is highly preferred and encouraged. EXPERIENCE:
Three years active patient or clinical care experience as a Registered Nurse required. Three years workers' compensation case management, occupational health, rehabilitation or insurance experience preferred. SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
- Knowledge of clinical care and jurisdictional requirements.
- Demonstrates the ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
- Strong time management skills.
- Excellent oral and written communication, customer service, written report preparation, human relations and decision making skills are required.
- Demonstrates use of critical thinking, attention to detail, sound clinical judgment and assessment skills for decision making.
- Proficient with computer and Microsoft Windows Suite.
- Demonstrates courteous, professional demeanor and team spirit and the ability to work in a collaborative, effective manner.
- Ability to make competent, independent decisions and maintain confidentiality where appropriate.
- Must be able to work independently as well as within a team
Work is performed in an office setting with no unusual hazards. Minimal travel.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.
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