Nurse Case Manager

SUMMARY:   

The Nurse Case Manager (NCM) is responsible for applying medical knowledge in reviewing workers’ compensation claims to assess, evaluate, plan, implement and oversee the treatment appropriateness for occupational injuries based upon evidence based guidelines.  The NCM utilizes clinical knowledge to evaluate the medical and disability needs of an injured worker against relevant policies, facilitate coordination of the patient’s medical treatment and timely return to work. The NCM engages the claimant and physician(s) in providing proactive medical and disability management, working collaboratively with claim handlers in providing focused claim resolution and return to work driven outcomes.  The case management process requires a focus on customer service, skills, knowledge of setting appropriate goals and measuring outcomes to effectively ensure optimal outcomes. 

Nurse Case Manager, Medical Bill Focus:

The NCM, Medical Bill Review applies medical knowledge during the process of reviewing complex workers’ compensation medical bills.  Review of bills includes the analysis of medical necessity/reasonableness of treatment as well as confirming medical bills and treatment are in concert with utilization review standards.  Additionally, evaluates medical claims/bills against relevant policies and statutes to determine claim resolution and communicates decisions to providers.  Responsible for monitoring the handling of all health cost disputes to ensure state guidelines are strictly adhered to.

RESPONSIBILITIES/TASKS: 

The nurse case manager must be able to demonstrate and be accountable for the standards of practice policies and procedures, quality assurance and the goals of the organization.  Also, manage treatment of claimants through the workers’ compensation system based on the individual’s diagnosis and state workers’ compensation regulations.

• Obtains and reviews patient clinical status and history to determine casual nature of patient’s symptoms as related to reported work injuries. 
• Applies knowledge of age-specific, cultural diversity, psycho/social and developmental issues during the interview process, documentation and intervention with the claimant, their family or significant other. 
• Determines the medical necessity/reasonableness of proposed and ongoing treatment as well as inpatient or outpatient hospitalization for each lost-time case. 
• Formulates all internal and external correspondence necessary to research and resolve case disputes and case inquiries, contacting providers and involving claims handlers as required.  Communicates final decision and subsequent ramifications to claim handlers. 
• Presents, discusses and finalizes alternative care and return to work programs with permanency ratings assigned to lost-time cases by medical providers, reinsuring the level of injury and ratings assigned are accurate and consistent with workers’ compensation, state, industry and division rating standards and policies, in conjunction with the claim  handler.
• As it relates to California: Adhere to California Nurse Practice Act, Case Management Code of Professional Conduct and Employee Code of Ethical Conduct

Nurse Case Manager, Early Detection:

In certain circumstances, working with the treating physician to coordinate the initiation of a substance abuse program or detoxification program. 

• Uses independent judgment and discretion in identifying and planning strategies to promote effective long term pain management and increase functioning.  Works in collaboration with the claimant, claims handler or physicians for changes in the treatment plan as required.  Provides claimant/family or significant other with information as needed for workers’ compensation services. 
• Research, utilize and document evidence based guidelines (EBG, ACOEM, and/or ODG) in the evaluation of the current and proposed treatment plan, specifically the use of opioids.
• Seeks consultation from physicians, clinical and other disciplines and departments as required to expedite treatment for the work related injury.
• Manages aspects of the planning process in anticipation of claimant variances or transitions.
• With respect to the individual claimant, analyzes and evaluates the effects of case management on quality outcomes, fiscal parameters, customer satisfactions and systems operations, and develops strategies to improve performance.

Nurse Case Manager, Medical Bill Review focus:

• Researches, analyzes, audits, and evaluates medical claims/bills and medical issues in comparison with state statues and the Company policies. 
• Monitors from point of receipt to the point of resolution all health cost state disputes.  This includes the production of all appropriate documentation associated with this process. 
• Reviews and researches case appeals to obtain all pertinent claim and medical information.  Resubmits for advisor review as appropriate and responds to provider in writing, indicating review decision’s outcome.
• Formulates internal and external correspondence necessary to research and resolve case disputes and case inquiries, contacting providers and involving claims representatives as required. Communicates final decision and subsequent ramifications to claims representatives.
• Responsible for monitoring and processing medical bills flagged for triage
• Responsible for monitoring, processing or assisting in review of medical bills flagged for negotiations.
• Responsible for review of medical bill reconsiderations as needed, taking into consideration the various statutes of limitations dictated by billing state.
• Establish a strong and professional working relationship with vendors.
• Collaborate and support with other Medical Billing staff team members.
• Review bills for $35,000 or greater for documentation and accuracy
• Collaborate with the Investigative Services Unit (ISU) regarding provider billing trends

This position description identifies the responsibilities and tasks typically associated with the performance of the position.  Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS

Registered Nurse license active and unrestricted required.  Bachelor’s degree in Nursing (BSN) preferred. Continuous learning required, as defined by the Company’s learning philosophy. Certification or progress toward certification is highly preferred and encouraged.

EXPERIENCE:

Three years active patient or clinical care experience as a Registered Nurse required. Three years workers’ compensation case management, occupational health, rehabilitation or insurance experience preferred. 

EXPERIENCE:  Nurse Case Manager, Medical Bill Review focus:

Three years prior workers’ compensation medical bill review/UR experience.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Knowledge of clinical care and jurisdictional requirements.
• Demonstrates the ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
• Strong time management skills.
• Excellent oral and written communication, customer service, written report preparation, human relations and decision making skills are required. 
• Demonstrates use of critical thinking, attention to detail, sound clinical judgment and assessment skills for decision making. 
• Proficient with computer and Microsoft Windows Suite.
• Demonstrates courteous, professional demeanor and team spirit and the ability to work in a collaborative, effective manner.

ADDITIONAL SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED: Nurse Case Manager, Medical Bill Review focus:

• Strong working knowledge of workers’ compensation laws. 
• Strong knowledge of CPT, ICD, HCPCS medical bill coding.
• Strong knowledge of CMS 1500 and UB04 and how they should be completed.
• Strong knowledge of state health cost dispute process.
• Must possess strong negotiation skills and decision-making ability. Attention to detail and analytical skills required.
• Ability to exercise good judgment in evaluating and determining the appropriateness of various actions within the process of workers compensation claims management.
• Ability to read, analyze and interpret policy documents, technical, legal and financial information and procedure manuals.
• Ability to make competent, independent decisions and maintain confidentiality where appropriate.
• Must be able to work independently as well as within a team

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards. Minimal travel.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description. 

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis.  Nothing herein is intended to create a contract.

PAY RANGE 

“Actual compensation decision relies on the consideration of internal equity, candidate’s skills and professional experience, geographic location, market and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $62,000 and $103,700.”

We are an Equal Opportunity Employer. We will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis.  Nothing herein is intended to create a contract.

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