Medical Case Manager
- Career Level
- Not Specified
This is a work from home position requiring local field case management travel.
To provide effective case management services in an appropriate, cost effective manner. Provides medical case management service which is consistent with URAC standards and CMSA Standards of Practice and Broadspire Quality Assurance (QA) Guidelines to patients/employees who are receiving benefits under an Insurance Line including but not limited to Workers' Compensation, Group Health, Liability and Disability.
- Reviews case records and reports, collects and analyzes data, evaluates injured worker/disabled individuals medical status, identifies needs and obstacles to medical case resolution and RTW by providing proactive case management services.
- Render opinions regarding case costs, treatment plan, outcome and problem areas, and makes recommendations to facilitate case management goals to include RTW.
- Demonstrates ability to meet administrative requirements, including productivity, time management and QA standards, with a minimum of supervisory intervention.
- May perform job site evaluations/summaries to facilitate case management process.
- Facilitate timely return to work date by establishing a professional working relationship with the injured worker/disabled individual, physician, and employer. Coordinate RTW with injured worker, employer and physicians.
- Maintains contact and communicates with claims adjusters to apprise them of case activity, case direction or secure authorization for services. Maintains contact with all parties involved on case, necessary for case management the injured worker/disabled individual.
- May obtain records from the branch claims office.
- May review files for claims adjusters and supervisors for appropriate referral for case management services.
- May meet with employers to review active files.
- Makes referrals for Peer reviews and IMEs by obtaining and delivering medical records and diagnostic films, notifying injured worker/disabled individual and conferring with physicians.
- Utilizes clinical expertise and medical resources to interpret medical records and test results and provides assessment accordingly.
- May spend approximately 70% of their work time traveling to homes, health care providers, job sites and various offices as required facilitating RTW and resolution of cases.
- Meets monthly production requirements and quality assessment (QA) requirements to ensure a quality product.
- Reviews cases with supervisor monthly to evaluate files and obtain directions.
- Upholds the Crawford and Company Code of Business Conduct at all times.
- Demonstrates excellent customer service, and respect for customers, co-workers, and management.
- Independently approaches problem solving by appropriate use of research and resources.
- May perform other related duties as assigned.
Associates degree or relevant course work/certification in Nursing is required.
Minimum of 3-5 years diverse clinical experience and one of the below
Certification as a case manager from the URAC-approved list of certifications;
A bachelors (or higher) degree in a health or human services related field;
A registered nurse (RN) license.
Valid RN licensure in the state(s) the incumbent works in.
Must meet specific licensing requirements to provide medical case management services.
Minimum of 1 National Certification (CCM, CDMS, CRRN, and COHN) is highly preferred. If not attained, must plan to take certification exam within proceeding 24 months and have a minimum of 4 years WC case management experience/demonstrated excellent performance in a similar position with another organization.
Travel may entail approximately 70% of work time.
Must maintain a valid drivers license in state of residence.
General working knowledge of case management practices and ability to quickly learn and apply workers compensation/case management products and services.
Excellent oral and written communications skills to effectively facilitate return-to-work solutions within a matrix organization and ensure timely, quality documentation.
Excellent analytical and customer service skills to facilitate the resolution of case management problems.
Basic computer skills including working knowledge of Microsoft Office products and Lotus Notes.
Demonstrated ability to establish collaborative working relationships with claims adjusters, employers, patients, attorneys and all levels of employees.
- BSN Degree is preferred.
Broadspire (www.choosebroadspire.com), a leading international third party administrator, provides risk management solutions designed to help clients improve their financial results. Broadspire offers casualty claim and medical management services to assist large organizations in achieving their unique goals, increasing employee productivity and reducing the cost of risk through professional expertise, technology and data analytics. As a Crawford Company, Broadspire is based Atlanta, Ga., with 85 locations throughout the United States. Services are offered by Crawford & Company under the Broadspire brand in Europe (www.Broadspire.eu), including the United Kingdom (www.BroadspireTPA.co.uk).
In addition to a competitive salary, Crawford offers you:
- Career advancement potential locally, nationally and internationally. Crawford & Company has more than 700 locations in 70 countries;
- On-going training opportunities through every stage of your career
- Strong benefits package including matching 401k; health, dental, and life insurance; employee stock purchase plans; tuition reimbursement and so much more.
Crawford & Company participates in E-Verify and is an Equal Opportunity Employer. M/F/D/V
Crawford & Company is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at Crawford via-email, the Internet or in any form and/or method without a valid written Statement of Work in place for this position from Crawford HR/Recruitment will be deemed the sole property of Crawford. No fee will be paid in the event the candidate is hired by Crawford as a result of the referral or through other means.