Registered Nurse Medical Case Manager
ADMs Medical Case Managers are responsible for making Case Management recommendations and providing consulting services to ADMs customers while conducting an analysis and assessment of the treatment plan developed by the treating physician. The Case Manager will monitor and provide oversight of the planning, coordination and implementation of the treatment plan, and make recommendations to the treating physician supported by evidence based guidelines when appropriate. Working as a collaborator between carriers, attorneys, medical care providers, employers and employees, you will closely monitor the progress of the injured worker, make recommendations to both, the insurance carrier and provider, and report results back to the employer and insurance carrier. This will ensure appropriate and cost-effective healthcare services are being provided by the treating physician and the health care facility leading to a medically rehabilitated individual who is ready to return to an optimal level of work and become permanent and stationary.
ADMs Medical Case Managers are classified as salaried exempt from overtime in accordance with California wage order 4-2001, and fall under both the professional and administrative exemptions.
Medical Case Managers provide recommendations and consulting services to providers and ADMs customers.
Provide Case Management services in a Workers Compensation environment, while focusing on the medical appropriateness of care is being implemented by the providers and their staff to injured workers with focus on obtaining cost savings by coordination and utilization of all services, ensuring that as soon as medically feasible, return-to-work or permanent and stationary status is achieved and case closure is warranted.
Serve as a collaborator to interpret and explain the treatment plan established by the provider to the individual on his/her disability.
Evaluate the medical and recovery needs of an injured worker after the initial contact assessment. Incorporate into the initial plan of action information obtained from the employer and provider.
Make appropriate recommendations to providers and claims professionals to expedite proper treatment based on ACOEM and Evidence Based Guidelines.
Evaluate treatment plans and documents outcomes. Track protocol management for appropriate utilization and delivery of medical services. Outcomes will be evidenced by satisfaction, appropriate delivery and quality of care being provided by the medical staff and timely recovery per evidenced based criteria and clinical guidelines. Return-to-work outcomes and length of disability outcomes are calculated and monitored according to criteria as published in the Medical Disability Guidelines.
Working with all providers to develop an overall treatment plan that ensures cost containment while meeting state and other regulators guidelines.
Working with employers on modifications to job duties based on medical limitations and the employees physical capabilities.
Address the return-to-work capability with the injured worker and provider. Obtain a job description from the employer and presents to the provider if appropriate and necessary.
Identify barriers to recovery and formulates an appropriate action plan to overcome these barriers.
Researching alternative treatment programs such as pain clinics, home health care, and work hardening.
Coordinating all aspects of the individuals enrollment into the programs, and then monitors his/her progress, in an effort to maximize cost containment and minimize time away from work.
Manage the file and insure providers are adhering to treatment guidelines and utilization criteria as determined by state-mandated guidelines, proprietary and nationally published protocols, as well as account requirements, assuring smooth delivery of services to injured workers or third party claimants.
Maintain patient privacy by ensuring that all medical records, case specific information and provider specific information are kept in a confidential manner, in accordance with state and federal laws and regulations.
Coordinate and attend injured workers treatment appointments and may assist with needed arrangements for his/her attendance at these appointments.
Documenting and reporting all Medical Case Management activity for accurate case management and billing procedures.
Develops detailed status reports utilizing Case Management experience and accepted practices and case recording documenting through ADMs Case Management Program (CMP).
Recording billing hours in accordance with case activity and billing practices of ADMs customers.
Maintains phone contact with all parties involved to monitor, update, and advance case activity to ensure the progress of the case in accordance with accepted treatment guidelines.
Manage the file pro-actively, utilizing all appropriate case management tools
Maintains credentials, advanced knowledge and specialized training in order to demonstrate professionalism within the Case Management industry while working with providers, and in dealing with injured workers.
Acquiring and maintaining knowledge of developments in the Medical Case Management field.
Keeping abreast of California workers compensation laws and regulations, as well as other issues related to the Case Management industry.
Medical Case Managers are not to engage in any treatment, whether direct or indirect, and at no time be engaged in the practice of nursing.
Skills and Experience
To perform the essential functions of the job for Medical Case Manager successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, advanced education and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Diploma, Associate or bachelors degree in nursing or bachelors degree (or higher) in a health or human services related field required.
Masters level and/or advanced study in a health-related field desired.
Workers Compensation and Medical Case Management Experience
Minimum of three (3) years Medical Case Management in Workers Compensation experience strongly preferred.
Minimum of five (5) years full time equivalent of direct clinical care to consumers required.
Knowledge, Skills and Abilities
Background in California state workers compensation law and practices desirable.
Must be eligible to pursue URAC-recognized certification in case management (CCM, CDMS, CRC, CRRN or COHN) upon eligibility.
Must be proficient in Microsoft Office suite with such programs as Word and Excel as well as have experience with internet searches and a comfort level with other software programs and general computer operations.
Excellent organizational, interpersonal skills and phone manners.
Must possess and have a valid drivers license and maintain a clean driving record acceptable to company insurance requirements.
Ability to set priorities, meet company QA dates and work independently is essential.
Registered nurse with current, valid state licensure required. NOTE: California does not require any licensure or certifications to perform the job of Medical Case Manager, however, ADM requires current RN licensure to maintain a peer-to-peer professional relationship with providers and claims professional and the ability to seek URAC-recognized certification in case management (CCM, CDMS, CRC, CRRN or COHN) upon eligibility.
Spanish speaking ability a plus.
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