Davies North America

Global insurance professional services and tech

Telephonic Nurse Case Manager

Medical, Clinical & VeterinaryUpdated on Nov 13

Full-timeRemote in USA$83k - $88k /yr

About the Job

Requirements

Must be a registered nurse with a minimum of three years of clinical experience in medical-surgical, orthopedic, neurological, intensive coronary care, industrial, emergency room, or occupational settings.
Must have at least three years of Workers’ Compensation experience.
Must provide proof of current state licensure; a compact license is preferred.
Must hold a California registered nurse license or be able to obtain California endorsement within six months.
Must maintain knowledge of current trends, standards, and law changes.
Must be self-directed and able to work independently.
Must be able to effectively operate a personal computer and related claims and business software.
Must have good oral and written communication skills, good attendance, and good customer service skills.

Responsibilities

Provide telephonic case management in a Workers’ Compensation environment, focusing on medically appropriate care for injured workers, cost savings through coordination and utilization of services, and timely return to work when medically feasible.
Facilitate communication among the employee, employee representative, employer, employer representative, insurer, health care provider, managed care organization, and, when authorized, qualified rehabilitation consultants to support case goals and customer relationships.
Build and maintain rapport with client contacts to support retention and meet or exceed client expectations while following policy and procedure.
Clinically evaluate an injured employee’s recovery needs after the initial contact assessment and incorporate information from the employer and provider into the initial plan.
Provide progressive education to injured employees and document it in the system.
Identify barriers to recovery and formulate action plans to address them.
Conduct ongoing assessments of health and medical records.
Monitor and audit provider and vendor performance and care.
Develop, track, and modify case-management care plans as appropriate.
Document data from interviews, contacts, and medical records in the computerized system.
Address return-to-work capability with the injured worker and provider at each medical evaluation, document it, and obtain and present the employer’s job description to the provider when necessary.
Manage files according to treatment guidelines, utilization criteria, state-mandated guidelines, published protocols, and account requirements to ensure timely delivery of services to injured workers or third-party claimants.
Evaluate treatment plans and document outcomes; track protocol management and service utilization and delivery against patient satisfaction, care quality, evidence-based criteria, clinical guidelines, return-to-work outcomes, and length-of-disability outcomes as published in the Official Disability Guidelines.
Proactively manage files using appropriate case-management tools.
Develop alternative treatment plans when necessary and adapt the case-management process to provide a more refined and efficient system.
Identify when utilization review procedures are needed, including medical director review, pre-certification, pre-authorization, concurrent review, and retrospective review of bills and reports; communicate and document findings.
Anticipate health needs during case management, educate patients and families, and encourage injured workers to participate in recovery plans.
Protect patient privacy by keeping medical records and case- and provider-specific information confidential in accordance with state and federal laws and regulations.
Act as a patient advocate and adhere to legal, ethical, accreditation, and regulatory standards.
Serve on committees such as Grievance and Quality Assurance as directed.
Negotiate provider fees or channel cases to other vendors as appropriate.
Train claims staff to identify medical case-management opportunities as needed.
Provide leadership to lower-graded staff in the department as needed.
Perform other duties as needed.

Desired Qualifications

Case-management experience is desired, with Workers’ Compensation experience preferred.

Our Story

Imagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.

What's in Store
Davies Claims North America is seeking an experienced Telephonic Nurse Case Manager to join our team. You will be responsible for the management and independent decision making on medical claims. You will analyze, evaluate and coordinate the delivery of high quality, timely, cost effective medical treatment and other health services as needed by an injured employee to promote an appropriate, prompt return to work when medically indicated. Manages all care throughout the continuum of services in order to achieve the highest level of quality medical care in the most cost effective and timely manner possible. You will perform ongoing assessments of the injured employee’s recovery to ensure high quality of care, reduce recovery time and minimize the effects of injury. Performs Telephonic Case Management activity on Workers’ Compensation cases according to parameters identified.

Must have California RN, or ability to obtain California endorsement within 6 months.

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 managed care organization and when authorized, any qualified rehabilitation consultant, to achieve the goals ensuring excellent customer relationships and quality customer service.
Build and maintain excellent rapport with client contacts to ensure retention; perform in manner to meet/exceed client expectations, following policy and procedure.
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.
Ensure appropriate, progressive education is provided to the injured employee in a consistent manner, and documented in the system.
Identify barriers to recovery and formulates an action plan to overcome these barriers.
Provide ongoing assessment of health and medical records.
Monitor and audit provider and vendor performance and care.
Develop case management care plan, track and modify 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.
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.
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 medical director 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.
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.
May train claims staff on the identification of medical case management opportunities.
May provide leadership of lower graded staff in the department.
Perform other duties as needed.

RN with a minimum of three years clinical experience (medical-surgical, orthopedic, neurological, ICCU, industrial, ER or occupational).
Workers’ Compensation experience 3+ years
Proof of current State Licensure, compact license preferred
California RN, or ability to obtain California endorsement within 6 months
Case-management experience desired – Workers’ Comp preferred.
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.

About the Company

Davies North America

Global insurance professional services and tech

Davies North America is a global professional services and technology company that began in the UK as an insurance claims manager. It now provides technology, consulting, and legal solutions to clients in regulated industries, including insurance, through managed services, outsourcing, and advisory offerings. The company grows by acquiring other businesses to expand its geographic reach and service capabilities. Its goal is to become a global leader in professional services and technology for regulated industries, particularly in markets like the US, Canada, and Bermuda.

Company size: 5,001-10,000
Company stage: Debt Financing
Total funding: $363M
Headquarters: London, United Kingdom
Founded: 1968

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