Clinical Case Manager (Mostly Remote)

UPMC's Health Plan is hiring a Clinical Case Manager for its Workers Compensation Case Management team.

This position is mostly remote but may require travel to Pittsburgh a few times a month.

Workpartners administers both occupational and non-occupational disability management programs for UPMC and external clients. Work Partners' Nurse Case Managers are responsible for assisting the claims staff and client in the medical and disability case management of all assigned cases.

Responsibilities:

• SPECIFIC RESPONSIBILITIES: Utilizing the essential case management activities of assessment, planning, implementation, coordination, monitoring, evaluation, outcomes, and general the case manager activities shall primarily include, but are not limited to the following: Participate as part of a multidisciplinary team in the management of specific account program assigned. o Provide `Best in Class' Nurse Case Management on all claims assigned. These claims may include all claims for our external client, both medical desk/ non-occupational and workers' compensation.
• Utilize standardized duration resources to guide return to work time lines and communicate with treating physicians in seeking clarification if injured employees fall outside anticipated durations.
• GENERAL RESPONSIBILITIES: In conjunction with the claims adjusters and treating medical personnel, the NCM will monitor each claim with the objective of assisting an employee in receiving any needed medical care as a result of their injury/illness, identifying physical capabilities that allow the employee to return to work as soon as is medically possible following standardized disability guidelines, identifying any known barriers that would prevent successful return to work, and collaborate in conjunction with treating provider(s) and claims staff to develop strategies to bring each claim to an anticipated successful close . In order to meet this objective, the NCM must be familiar with the worlds of occupational and non-occupational medicine; and with the medical details of each injury/illness, including the current treatment and the anticipated return to work date.
• Keep claims adjusters or non-occupational client apprised of an employee's progress and medical status (maintaining HIPAA privacy standards for client interaction). Document all information in a timely manner in the claims system and maintain diary system. o Review medical information and provide feedback to claims staff with regards to the causal relationship of the work injury to the medical evidence provided. o Actively monitor employees' care and progress during an injury or illness and interact with appropriate panel provider/treating physician to assure understanding of the treatment plan o Prepare in whole or in part (along with the claims adjusters) letters to physicians, letters regarding Independent Medical Evaluations, or other documentation requiring a medical perspective
• Review reports: weekly, monthly and quarterly to evaluate the effectiveness of the medical delivery system, and to identify trends and cost containment opportunities. o Target specific high cost drivers and develop strategies to minimize the impact of such on the overall cost of the program