Telephonic Medical Case Management (Workers' compensation)

## Telephonic Medical Case Manager (Workers' compenasation)

**POSITION 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.

**Primary responsibilities include:**

• Provide telephonic outreach for assessment, and follow up for case communication and coordination to include assessing, planning, implementing, coordinating of care
• Conducts and documents initial assessment with the injured worker, employer and provider and maintain regular contact with all parties involved to facilitate communication and to 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

## Qualifications
**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 Registered Nurse (RN), Licensed Practical Nurse (LPN) and or Certified Case Manager (CCM) license required
• CCM, CMCN, CPHUR, 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 acute care
• Two or more years of medical case management or managed care experience, Worker’s Compensation background preferred
• Knowledge of utilization management, quality improvement, discharge planning, and or cost management.
• Ability to solve practical problems and deal with a variety of variables.
• Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
• Excellent interpersonal skills and excellent organizational skills.
• Ability to set priorities and work independently is essential
• Proficient with Microsoft Office applications including Word, Excel, and Power Point

• **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

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| **MENTAL AND PHYSICAL REQUIREMENTS** |

| **1. MENTAL EFFORT** a. Reasoning development: Follow one- or two-step instructions; routine, repetitive task. Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. X 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. |

| b. Mathematical development: Simple additional and subtraction; copying figures, counting, and recording. Add, subtract, multiply, and divide whole numbers. X Arithmetic calculations involving fractions, decimals, and percentages. Arithmetic, algebraic, and geometric calculations. |