Telephonic Nurse Case Manager

Key Responsibilities Provide telephonic case-management in a Workers’ Compensation environment.

Focus on medical appropriateness of care to injured worker with cost savings by coordination and utilization of all services, ensuring that as soon as medically feasible, return-to-work status is achieved, along with increase in productivity.

Facilitate communication between the employee, the employee representative, employer, employer representative, insurer, health care provider, the medical services organization and when authorized, any qualified rehabilitation consultant, to achieve the goals Clinically evaluate the recovery needs of an injured employee after the initial contact assessment.

Incorporate into the initial plan information obtained from the employer and provider.

Identify barriers to recovery and formulates an action plan to overcome these barriers.

Provide ongoing assessment of health and medical records.

Monitor and audit health provider ensuring licensure and appropriate care.

Monitor vendor performance, ensuring quality service.

Develop case management care plan, tracks and modifies appropriately Appropriately document all data received from interviews, contacts and medical records in the computerized system.

Address the return-to-work capability with the injured worker and provider at each medical evaluation.

Document appropriately in computerized system.

Obtain a job description from the employer and presents to the provider if necessary.

Verify disability against approved guidelines, questioning variances.

Manage the file adhering to treatment guidelines and utilization criteria as determined by the state-mandated guidelines, proprietary and nationally published protocols, as well as account requirements, assuring smooth delivery of services to injured workers or third party claimants.

Create, edit and/or revise correspondence.

Evaluate treatment plans and documents outcomes.

Track protocol management for appropriate utilization and delivery of medical services.

Outcomes will be evidenced by patient satisfaction, appropriate delivery and quality of care and timely recovery per evidenced based criteria and clinical guidelines.

Return-to-work outcomes and length of disability outcomes are calculated and monitored according to criteria as published in the Official Disability Guidelines.

Manage the file pro-actively, utilizing all appropriate case management tools.

Develop alternative treatment plans when necessary.

Demonstrate the ability to accommodate changes on the case-management process for delivery of a more refined and efficient system.

Identify the need for utilization review procedures to claims, such as triggers that might indicate a potential barrier to recovery.

UR tools include physician advisor review, pre-certification, pre-authorization, concurrent review and retrospective review of bills and reports.

Communicate the findings determined in utilizing these tools and document appropriately.

Anticipate health needs during case-management process and educate patient and family appropriately.

Encourages the injured worker to participate in the recovery plan.

Review medical bills for appropriateness and forward bills to Bill Review/Cost Containment Organization for adjudication.

Maintain patient privacy by ensuring that all medical records, case specific information and provider specific information are kept in a confidential manner, in accordance with state and federal laws and regulations.

Serve as a patient advocate adhering to all legal, ethical and accreditation/regulatory standards.

Serve on appropriate committees such as Grievance, Quality Assurance and others as directed.

May negotiate fees with providers or channel cases to other vendors as appropriate.

Maintains contracted State of Florida performance standards for case management.

May train claims staff on the identification of medical case management opportunities.

May provide leadership of lower graded staff in the department.

Skills, knowledge & expertise At least one year’s experience handling Florida Workers’ Compensation case management or Florida Occupational Health experience (contractual requirement).

Maintains knowledge of current trends, standards and law changes.

Must be self directed and able to work independently.

Ability to effectively operate a personal computer and related claims and business software.

Good communication skills, both oral and written.

Team player.

Good attendance.

Good customer service skills.

RN with a minimum of three years clinical experience (medical-surgical, orthopedic, neurological, ICCU, industrial or occupational).

Proof of current State Licensure.

Bilingual – fluent English/Spanish helpful.