JOB DESCRIPTION TITLE: Telephonic Nurse Case Manager DEPARTMENT: Claims REPORTS TO: Manager of Nurse Case Management Services Date Last Reviewed: January 2018 SUMMARY: This is a responsible administrative level position The role of the Case Manager is to assure that patients have access to quality, cost effective heath care, and to assist in the assessment, development and coordination of a proactive plan in order to ensure the best outcome for the work injury. The role of case manager addresses early return to work and coordinates the return to work with the policyholder, the treating physician and the claims representative. The nurse case manager will facilitate a safe, effective, early return to work. The telephonic nurse case manager position is an entry level position to case management. ESSENTIAL DUTIES AND RESPONSIBILITIES: Other duties may be assigned. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Provide leadership to the nurse case management team in accordance with MEM s vision, mission and values Identifies and screens potential cases for possible case management based on MEM Step Criteria for Case Management Referral Performs files reviews on the less severe claims, as necessary to give input on the medical treatment plan Carry an active inventory of files requiring active telephonic case management at a level based on the time demands required by the other essential functions listed herein Collects/assesses data from referral source and medical treatment providers Accepts case management assignments based on own education, experience and areas of expertise.
Initiates telephonic contact with the injured employee, policyholder, therapists and medical providers as per the claims standards. Initiates and develops ongoing telephonic communication with providers of treatment in order to promote quality care that is medically necessary, for the best possible outcome for the work injury May be expected to cover an onsite task appointment when the onsite nurse case manager is unavailable Expected to create task assignments to onsite nurse if acuity of treatment requires an in person visit Coordinates and manages medical treatment plan Obtains detailed initial health history and from injured worker Obtains detailed job description from injured worker and Policyholder Identifies services and treatment options medically necessary to provide/promote quality care for the work injury Reviews treatment plan with all involved participants Acts as advocate for patient s needs when indicated within the confines of the workers compensation system. Identifies and explores gaps or inadequacies in treatment plan in order to avoid fragmented medical treatment Develops individual medical treatment plan for specific patient s needs Maintains confidentiality of information and obtains appropriate consents/authorizations Evaluate the injured worker s potential for return to work and how that may impact the rehabilitation process. Taking into consideration socioeconomic factors, education, and vocational history In cooperation with the medical service providers, the injured worker and the policyholder, establish a return to work target date. Wherever possible and consistent with sound medical judgment, search for light duty options to return the injured employee to safe, gainful employment as soon as possible Establishes relationship with injured worker, family, and medical providers to achieve optimal outcomes. Work closely with all parties to effect maximum medical improvement while controlling costs and maintaining quality of care. In cases where the injured worker cannot return to the former job, makes appropriate recommendations regarding vocational rehabilitation to the claims representative Maintains communication with all the parties involved in the claim Makes appropriate recommendations and establishes achievable goals for all parties to the claim Updates all participants as necessary regarding any treatment plan changes Maintains and records case management activity Documents activity on the medical management screen within the appropriate array within the ClaimsCenter system
Accomplishes ongoing documentation within the current claim s standard Communicates activity concerning the medical treatment plan and early return to work issues to all parties involved in the claim Includes accurate cost analysis when closing claim to nurse case management and documents cost savings when realized Maintains ongoing communication with supervisor Updates supervisor in meetings, as scheduled or impromptu meetings, regarding any injured workers status Consults with supervisor when direction is required on a case or when sensitive issues regarding the case or injured worker arise Represents MEM in professional activities in the health care community, and internally Attends conferences, seminars, and when requested, performs calls/meetings with policyholders or producers Works in the office and serves as a resource to claims representatives and other staff members at MEM. Works with claims representatives and other staff members to discuss or educate on them on the concepts of nurse case management Explains and demonstrates nurse case management programs to customers, as requested. Acts as a mentor for less experienced and newly hired nurse case managers. Obtains and utilizes information pertaining to all facets of position responsibilities. Keeps a current file of articles, community resources and in-service information pertaining to nurse case management and health care resources Attends, or is responsible, for presenting information when asked during staff meetings. Management Responsibilities Calendar for daily activities and medical treatment Reviewing/management of medical records and information Interpersonal/written communication between all parties of the claim concerning medical treatment/return to work Coordinates/manages medical treatment plan for the work injury Early return to work issues for the injured worker Communication with supervisor/manager Obtaining continuing educations units required for licenses/certifications Oversee auto assignment of medical exposure to nurse case management team Oversee assignment to external vendor nurses as dictated by Manager
Non-Management Responsibilities Answering/returning telephone calls Faxing information to parties of the claim Data entry into claims system Email communication Researching medical information QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Education: Associate nursing degree/graduate of a diploma RN program or Bachelors Degree in nursing Certification in Case Management from the Case Management Society of America or similar certification or eligibility to obtain Experience: At least three years of nursing experience is required in Medical/Surgical areas. A background in Home Health is applicable. Five years insurance case management experience preferred. Designations/Certifications: Certification in Case Management from Case Management Society of America preferred Other certifications considered LICENSES Current unencumbered RN license from the Missouri State Board of Nursing or an unencumbered RN license from a compact state Current/Eligibility for Missouri State Drivers license LANGUAGE SKILLS: Ability to read and comprehend basic/complex instructions given from written and oral sources. Ability to write basic/complex correspondence. Ability to effectively present information to top management, employees, and the public. Ability to read, writes, speak and comprehend English fluently. Must be able to communicate effectively in person, on the telephone, and in writing, using correct grammar, punctuation, spelling and sentence structure Must be able to carry on conversations with medical providers, insured, and injured workers in a style, which facilitates good understanding by all parties.
MATHEMATICAL SKILLS Ability to understand basic mathematical relationships and formulas. Ability to understand and employ basic/complex accounting mathematics. REASONING ABILITY Ability to work with little or no supervision. Ability to use common sense techniques in solving problems. Ability to solve complex logical problems. Ability to use diplomacy and tact when dealing with problems. Ability to identify problems and determine the best course of action for their resolution. Ability to critically evaluate information for accuracy and usefulness in solving problems. Ability to deal with problems involving several concrete variables in a variety of situations. COMPUTER SKILLS AND ABILITIES Basic/expert level of knowledge of word processing, excel software and presentation software. PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Fingers to feel/handle/use tools and equipment Hands to use tools and equipment. Arms to Lift 25 pounds Carry 25 pounds 50 feet Sit Stand Stoop Crawl Climb Twist Jump Walk Run Close Vision Distant Vision Color Vision WORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
You may be exposed to: Water Smoke Heat Cold Air particles Falling materials Electrical shock Hazardous chemicals Fire Emergency vehicle traffic Low noise Moderate Noise Loud Noise