Medical Case Manager

Positions available at our Rocklin, CA location

Summary

The Medical Case Management nurse ensures achievement of maximum medical and disability improvement through early, proactive intervention. These activities emphasize quality care through coordination of cost-effective appropriate treatment. These objectives are obtained by communication with the primary care physician, the injured worker, the employer, claims adjustor and all other parties involved in facilitating the best possible outcome for the given claim. The Medical Case Management nurse is aware the claims adjustor is ultimately responsible and accountable for the outcome of these claims and no intervention is undertaken without their authority and direction. The Medical Case Management nurse is seen as the patient’s advocate and as the representative of the insured and must be able to satisfy the needs of all concerned while being objective and effective.

Essential Duties and Responsibilities

  • All claims assigned are triaged within 24 hours.
  • A 3-point contact {employee, employer, Primary Care Physician} and documentation is to be completed on all files referred within 72 hours. [when applicable]
  • When needed Disability management is initiated to identify anticipated lost time and coordinate the return to work process.
  • All Utilization Review for California will be in compliance with Labor Code and the California Code of Regulations.
  • The Medical Case Management nurse will address all medical issues for the claim assigned and coordinate as needed to insure optimum outcome with timely and appropriate medical care.
  • Will receive and review referrals for treatment for medical appropriateness of treatment plan based on accepted evidence based guidelines and best practices.
  • Will identify the medical diagnosis and treatment plan; validate diagnosis and corresponding algorithms of care.
  • Will review treatment protocols and make recommendation using local, regional, and national recognized evidence base guidelines such as ACOEM, M&R, ODG, as well as documentation provider by the PTP.
  • Will evaluate for over-utilization of treatment requests inconsistent with evidence based guidelines and when possible, negotiate with provider to modify the treatment request when appropriate.
  • Will direct and maximize the utilization of PPO/MPN networks.
  • Pre-authorization of all appropriate inpatient and outpatient procedures.
  • Will communicate with the claims examiner, providers, attorneys and any other auxiliary provider regarding UR determination in the prescribed given time frame followed in written within 24 hours.
  • Will summarize medical records and all pertinent information presented with recommendation to Physician Advisor and/or prepare questions on complex cases for peer or third party review.
  • Will work closely with the client, claims handler, nurse case manager and supervisor, and take directions when needed.

Qualification Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

Current and valid California RN or LVN license
Minimum of 3 years clinical experience
Must be familiar with California Worker’s Compensation, Managed Care experience/Utilization Review experience recommended

Additional Criteria:

Bilingual (Spanish) preferred, not required
Multi-jurisdictional state RN licensed (Texas RN license a plus)
Ability to work in an office setting (non-clinical setting)
E.R./ICU /Critical Care Experience (a plus)
Triage Nurse experience (a plus)
Current Unrestricted California Licensure for specialties meeting the requirements for this job.


Qualified candidates who are interested in joining our growing team should email your resume to: HR@Intercareins.com


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