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Rising Medical Solutions

Medical cost containment and care management

TCM/FCM Hybrid Nurse Case Manager

Medical, Clinical & VeterinaryConfirmed live in the last 24 hours
Full-timeRemote in USA

About the Job

Requirements

  • Maintain a current, active, unrestricted registered nurse license in the primary residence state; a compact-state license is preferred.
  • A California registered nurse license is a plus.
  • Currently reside in Pennsylvania, Tennessee, Florida, Texas, or Indiana.
  • Work full-time from 9:00 a.m. to 5:30 p.m. Central Standard Time, with the ability to flex hours based on the jurisdiction.
  • Have strong computer skills, including Microsoft Outlook, Excel, and Word.
  • Have 3–5 years of case management experience, including 1–2 years of workers’ compensation nurse case management experience.
  • Have experience with workers’ compensation, liability, or disability claims.
  • Maintain confidentiality of all information, policies, and procedures.
  • Set priorities and work both autonomously and as part of a team.
  • Demonstrate sensitivity to culturally diverse people and situations.
  • Have well-developed time management, organization, and prioritization skills.
  • Know utilization management, case management, and healthcare across the health continuum.
  • Have oral and written communication skills, with a strong focus on customer service.
  • Gather data, compile information, and prepare summary reports.
  • Have interpersonal and conflict-resolution skills.
  • Have experience working in a fast-paced, multifaceted environment.
  • Demonstrate persistence and attention to detail.
  • Stay calm during stressful situations.
  • Hold a Professional Nursing degree, such as an Associate of Science in Nursing or Bachelor of Science in Nursing.

Responsibilities

  • Maintain a mixed caseload of field and/or telephonic case management files, typically 30–40 cases.
  • Establish collaborative relationships and serve as an intermediary among clients, injured or disabled individuals, employers, providers, attorneys, and other involved parties.
  • Manage high-risk, high-cost, and complex cases by assessing clinical, functional, psychosocial, and vocational needs.
  • Assess, coordinate, implement, monitor, and evaluate individualized care plans using principles of medical necessity, appropriateness of care, case management, and managed care.
  • Promote quality, cost-effective care across the healthcare continuum to support optimal function and safe, timely return to work when appropriate.
  • Assess injury severity, extent of disability, treatment plans, functional abilities, and physical job requirements to develop return-to-work strategies and help manage future medical exposure.
  • Track and report case management activity, maintaining organized, timely, and accurate clinical documentation of interactions, interventions, barriers, outcomes, and communications.
  • Respond to written and telephonic inquiries regarding case status and document relevant case information in Rising systems and client claims systems when applicable.
  • Adhere to applicable state, national, accreditation, departmental, and client-specific quality standards, guidelines, policies, procedures, and reporting requirements.
  • Escalate potential clinical, operational, service, or compliance concerns to the appropriate supervisor as they become evident.
  • Assist with URAC accreditation activities and maintain related policies and procedures.
  • Provide professional nursing insight to Rising Medical Bill Analysis and other internal teams as requested.

Desired Qualifications

  • Medical bill review experience with workers’ compensation, auto, or health insurance carriers is preferred.
  • Certified Case Manager (CCM) or other insurance/workers’ compensation certifications are a strong plus.
  • A compact-state registered nurse license is preferred.
  • A California registered nurse license is a plus.

About the Company

Rising Medical Solutions

Medical cost containment and care management

Rising Medical Solutions is a national managed care firm offering medical cost containment and care management for workers’ compensation, auto, liability, and group health markets. Its flagship bill review saves over 60% by applying fee schedules, network discounts, nurse audits, provider negotiations, and fraud detection, while its broader programs cover the full medical care continuum. The proprietary VISION platform is a single-sign-on medical management system that provides claims professionals with referrals and management tools across the entire care process. The company also publishes the annual Workers’ Compensation Benchmarking Study to inform the industry and drive improvements in claims management. Its goal is to lower claim costs, improve care outcomes, and deliver a smooth experience for everyone involved in the medical care and claims process.

Company size
51-200
Company stage
Not listed
Total funding
Not listed
Headquarters
Chicago, IL
Founded
1999

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