Nurse Case Manager

JOB SUMMARY

Case management is a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health and/or disability needs through communication and available resources to promote quality cost-effective outcomes. The Nurse Case Manager handles a variety of types of case management that may include workers’ compensation, case management in the medical health plan administration setting, as well as health management, disease management, and absence management.

ESSENTIAL FUNCTIONS

• Conducts initial and ongoing assessments to identify patient status and individual needs; promotes client self-determination
• Assists in identifying appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source.
• Utilizes appropriate resources and case management interventions to facilitate the case management plan and to allow for the individual’s optimum level of wellness and functional capability with quality cost-effective outcomes appropriate to health plan and workers’ compensation
• Develops a specific case management plan in collaboration with the consumer and members of the health care team with periodic updates. Identifies short term goals, long term goals, interventions to meet goals, resources to be utilized, timeframes for re-evaluations, and collaborative approaches to facilitate the case management plan
• Executes and documents specific case management activities and/or interventions that will lead to accomplishing the goals set forth in the case management plan
• Gathers sufficient information from all relevant sources and its documentation regarding the case management plan and its activities and/or services to enable the determination of the plan’s effectiveness
• Evaluates at appropriate intervals, determining and documenting the case management plan’s effectiveness in reaching desired outcomes and goals with modifications, as appropriate
• Measures and modifies the interventions to determine the outcomes of the case management involvement
• Implements care plan by facilitating authorizations and referrals, as appropriate, within benefit structure, contractual agreements or jurisdictional regulations; utilizing nationally accepted evidence based criteria as guidelines for treatment protocols
• Notifies claims personnel regarding anticipated surgeries, benefit exceptions, and other significant events that may require special handling
• Manages the disability durations proactively, utilizing nationally accepted evidence-based criteria as guidelines for duration protocols in workers’ compensation and short term disability
• Collaborates and communicates effectively with patients/injured workers, providers, client, employers, and internal team members
• Performs Health Management Program and Chronic Condition /Disease Management according to protocols and standards, as required by benefit plans.
• Performs triage intake functions with referrals and coordination of care needs specific to client instructions.
• Performs short term disability management according to regulations, policies, and plan documents

REQUIRED QUALIFICATIONS

Registered Nurse

• 1 years of workers’ compensation case management experience
• 2 years of clinical experience
• Excellent written and verbal communication skills
• Proven customer service skills
• Effective time management skills
• Overall computer proficiency including expertise in Microsoft Office Suite, especially Outlook, Word, and Excel
• Licenses and Certifications

• Licensure or certification in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline;
• Two years full-time equivalent of direct clinical care to the consumer; and
• At least one of the following:

i. Certification as a case manager from the URAC-approved list of certifications; or
ii. A bachelor’s or higher degree in a health or human services related field; or
iii. A current registered nurse (RN) license

4. Willingness to obtain advanced certification, when eligible
5. Willingness to obtain additional state licensure, as required by business needs

PREFERRED QUALIFICATIONS

• Advanced/board certification in case management
• Additional case management/utilization review experience will be considered

SCHEDULE

8:30 a.m. to 5:00 p.m. Monday through Friday. Summer hours (Memorial Day to Labor Day) 8:00 a.m. to 5:00 p.m. Monday through Thursday and 8:30 a.m. to 3:00 p.m. Friday.

Work from home position

TRAVEL

Occasional travel to clients and business partners. Valid driver's license is required.