Medical Case Manager

Roles and Responsibilities:
• PH Registered nurses to review workers compensation claims with serious injury and that need surgery/lengthy treatments, create a return-to-work plan, work with various stakeholders (medical providers, injured worker, employer, attorney) to track the treatment plan and help bring the injured worker back to work.
• Nurses have continuous communication with injured workers and as a single point of contact for the injured workers
• Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered.
• Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary
• Responsible for accurate comprehensive documentation of case management activities in case management system.
• Uses clinical/nursing skills to help coordinate the individual’s treatment program while maximizing quality and cost-effectiveness of care including direction of care to preferred provider networks where applicable.
• Addresses need for job description and appropriately discusses with employer, injured employee and/or provider. Works with employers on modifications to job duties based on medical limitations and the employee’s functional assessment.
• Responsible for helping to ensure injured employees receive appropriate level and intensity of care through use of medical and disability duration guidelines, directly related to the compensable injury and/or assist adjusters in managing medical treatment to drive resolution.
• Communicates effectively with claims adjuster, client, vendor, supervisor, and other parties as needed to coordinate appropriate medical care and return to work.
• Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client’s situation to include psychosocial needs, cultural implications, and support systems in place.
• Objectively and critically assesses all information related to the current treatment plan to identify barriers, clarify, or determine realistic goals and objectives, and seek potential alternatives.
• Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome.
• Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim.
• Engage specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director).
• Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves.
• Keeps current with market trends and demands.
• Performs other functionally related duties as assigned.

Required Qualifications:
• Bachelor’s degree in nursing (BSN)
• Active unrestricted RN license that can be validated thru PRC website
• 1-2 years of relevant Clinical experience in any medical/surgical department, Orthopedic, Medical/Surgical ICU, Coronary Care Unit (CCU), Rehabilitation, Emergency department
• Written and verbal fluency in English
• Candidate should be willing to work onsite (BGC)
• Candidate should be willing to work in US operation hours