ICW Group Insurance Companies is recognized nationally as an insurance leader in helping policyholders achieve fewer and less costly claims in both Property & Workers' Compensation. We are looking to add a Telephonic Nurse Case Manager to our team.
ABOUT YOUR JOB
The purpose of this job is to perform clinical assessment and evaluate needs for treatment in workers compensation claims. The Telephonic Nurse Case Manager will negotiate and coordinate appropriate medical treatment and length of disability with providers and employers while managing financial and other risk on behalf of the Company.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Creates and manages workers compensation patient case plans with ongoing monitoring to ensure quality and appropriate service delivery of the case management process
- Perform initial and ongoing clinical assessment via telephone calls to the injured worker, employer, physician and attorney.
- Assesses client's situation for psychosocial needs, cultural implications and ensures support systems in place.
- Creates a case management plan based on the assessment with measurable goals and objectives utilizing evidence-based criteria.
- Monitors ongoing progress toward established goals and objectives.
- Implements plan through case management interventions and communication with all parties to reach desired goals and objectives.
Measures effectiveness of treatment plans and creates alternate strategies when needed
- Recommends need for alternative treatment plans using systematic and objective procedures set by the Company.
- Negotiates appropriate level and intensity of care and disability duration with providers through use of medical and disability duration guidelines, adhering to quality assurance standards.
- Negotiates and coordinates a prompt return to work with employer.
- Measures and reports on interventions to determine the outcome of the case manager's involvement to include clinical, financial, variance, quality of life, and client satisfaction.
- Maintains accurate record of management including costs, savings and demographic data.
Communicates effectively with all parties involved in injured workers treatment
- Provides case direction to field case specialists when on-site intervention is required; ensures quality and appropriate service delivery.
- Communicates effectively with medical providers, the assigned claims examiner, injured worker and policyholder and/or handling attorneys on any given case.
- Maintains injured worker's privacy and confidentiality, promotes safety and advocacy and adheres to ethical, legal, accreditation and regulatory standards.
- Interfaces with external agencies in relation to the utilization review process including, Third-Party Payers, Insurance Companies and Providers.
- Performs Utilization Review activities and reviews timely reports with clients and providers.
EDUCATION AND EXPERIENCE
Current unrestricted Registered Nurse (RN) or Licensed Vocational Nurse (LVN) and 1+ year of professional experience providing direct clinical care required. Bachelors degree (B.A. or B.S.) from four-year college or university in nursing (BSN) preferred. Equivalent combination of education and experience may be considered.
CERTIFICATES, LICENSES, REGISTRATIONS
Certification in case management, rehabilitation nursing or a related specialty is strongly preferred.
KNOWLEDGE AND SKILLS
Ability to work with medical and mathematical concepts such as diagnoses, probability and statistical inference. Ability to compute mathematical frequency and percentages. Ability to apply principles of logical, sounds judgement or medical thinking to a wide range of intellectual and practical problems. Ability to combine disparate skills and thinking to craft solutions to moderate to complex problems. Ability to hypothesize on root cause of inefficiencies in treatment and then articulate probable solutions. Ability to read, analyze, and interpret documents such as medical reports and health information of all types, industry journals, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, injured workers and members of the business community. Must be able to read, write and speak English effectively. Ability to effectively present information to ICW staff, and external audiences.
While performing the duties of this job, the employee is frequently required to sit. The employee is regularly required to stand; walk; reach with hands and arms; stoop, kneel, crouch, or crawl; talk and hear. The employee must occasionally lift and/or move up to 30 pounds. Specific vision abilities required by this job include close vision. The worker is required to have visual acuity and be capable of operating and viewing computers and other electronic devices for extended periods of time.
This position maps to the Individual Contributor level. Additional competencies required: None.
The noise level is usually quiet in the work area with moderate noise in the computer room.
Occasional travel may be required.