Nurse Case Manager

JOB REQUIREMENTS: SUMMARY: 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. Nurse Case Manager, Medical Bill Focus: The NCM,

Medical Bill Review applies medical knowledge during the process of

reviewing complex workers\' compensation medical bills. Review of bills

includes the analysis of medical necessity/reasonableness of treatment

as well as confirming medical bills and treatment are in concert with

utilization review standards. Additionally, evaluates medical

claims/bills against relevant policies and statutes to determine claim

resolution and communicates decisions to providers. Responsible for

monitoring the handling of all health cost disputes to ensure state

guidelines are strictly adhered to. RESPONSIBILITIES/TASKS: 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 Nurse Case Manager, Early Detection: In

certain circumstances, working with the treating physician to coordinate

the initiation of a substance abuse program or detoxification program.

\* Uses independent judgment and discretion in identifying and planning

strategies to promote effective long term pain management and increase

functioning. Works in collaboration with the claimant, claims handler or

physicians for changes in the treatment plan as required. To view the

full job description please use the link below.

\*\*\*\*\* APPLICATION INSTRUCTIONS: Apply Online:

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