Telephonic Medical Case Management (Workers' compensation)

Job Details: Level: Experienced, Job Location: Involuntary Remote TMC - Remote, SC, Position Type: Full Time, Education Level: High School Diploma or GED, Salary Range: $85000.00 - $92000.00Salary/year, Travel Percentage: None, Job Shift: Day, Job Category: Admin - Clerical, POSITION SUMMARY: The medical case manager provides telephonic case management in a workers’ compensation environment coordinating resources and cost effective options on a case-by case basis to facilitate quality individualized treatment goals and return to work placement.

ESSENTIAL DUTIES AND RESPONSIBILITIES: Possess excellent communication and organizational skills to interface with the client, claimants and staff. Work well independently and set priorities.

Primary responsibilities include:

Provide telephonic outreach for assessment, and follow up for case communication and coordination to include assessing, planning, implementing, coordinating of care
Conducts and documents initial assessment with the injured worker, employer and provider and maintain regular contact with all parties involved to facilitate communication and to formulate a clinical case plan

Responsible for coordination of contact with provider, claimant, RTW contact and claims examiner
Reviews case records and reports, collects and analyzes data, evaluates client's medical status and defines needs and problems in order to provide proactive case management services
Assessment of medical records for appropriateness of treatment and level of care being provided. Referral to the Medical Director if appropriate within the established timeframes
Facilitate timely return to work date coordinating RTW with the claimant, employer and physicians
Maintains contact and communicates updated activity with all parties involved with the case
Telephonically monitor medical appointments of the injured worker to address RTW, current treatment plan and identify potential issues and promote positive treatment outcomes. Negotiate treatment plan with treating physician

Additional Functions and Responsibilities

Demonstrates ability to meet administrative requirements, including productivity, time management and Quality Assurance standards
Maintain minimum billing and established template documentation standards adhering to URAC standards and company policy and procedures
Reporting billing hours in accordance with case activity and billing practices
Maintain confidentiality- Knowledge of laws and regulations pertaining to HIPPA and PHI
Other job duties as assigned

Qualifications: Education: 

Diploma, Associate or Bachelor’s degree in Nursing, Master’s level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred
Current, unrestricted Registered Nurse (RN), Licensed Practical Nurse (LPN) and or Certified Case Manager (CCM) license required
CCM, CMCN, CPHUR, CPDM,  COHN or CDMS certification preferred

Experience:

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.

Three or more years of diverse clinical experience in acute care
Two or more years of medical case management or managed care experience, Worker’s Compensation background preferred
Knowledge of utilization management, quality improvement, discharge planning, and or cost management. 
Ability to solve practical problems and deal with a variety of variables. 
Possess planning, organizing, conflict resolution, negotiating and interpersonal skills. 
Excellent interpersonal skills and excellent organizational skills.
Ability to set priorities and work independently is essential
Proficient with Microsoft Office applications including Word, Excel, and Power Point

EQUIPMENT OPERATED/USED:

Essential Equipment: Desk, Telephone/Fax, Computer Keyboard, Mouse, System Applications

Essential Tools: Pens, pencil, computer, Keyboard

Essential Vehicles:  N/A 

SPECIAL EQUIPMENT OR CLOTHING:

Professional attire adhering to the Company Dress Code

                             MENTAL AND PHYSICAL REQUIREMENTS

1.  MENTAL EFFORT

a.  Reasoning development:

          Follow one- or two-step instructions; routine, repetitive task.

          Carry out detail but uninvolved written or verbal instructions; deal with a few concrete                            variables.

          Follow written, verbal, or diagrammatic instructions; several concrete variables.

 X      Solve practical problems; variety of variables with limited standardization; interpret instructions.

          Logical or scientific thinking to solve problems; several abstract and concrete variables.

          Wide range of intellectual and practical problems; comprehend most obscure concepts.

b.  Mathematical development:

          Simple additional and subtraction; copying figures, counting, and recording.

          Add, subtract, multiply, and divide whole numbers.

 X      Arithmetic calculations involving fractions, decimals, and percentages.

          Arithmetic, algebraic, and geometric calculations.

          Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.

          Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.

c.       Language development:

          Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.

          Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.

          Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.

 X      Ability to compose original correspondence, follow technical manuals, and have increased contact with people.

          Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

2.  PHYSICAL EFFORT

a.       Physical activity required to perform the job:

          Sedentary work:  Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time.  Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

 X      Light work:

a.    Exerting up to 20 pounds of force occasionally

b.    Exerting up to 10 pounds frequently

c.    Exerting a negligible amount of force constantly to move objects

          (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).

          Medium work:

a.    Exerting up to 50 pounds of force occasionally

b.    Exerting up to 20 pounds of force frequently

c.    Exerting up to 10 pounds of force constantly to move objects

          Heavy work:

a.    Exerting up to 100 pounds of force occasionally

b.    Exerting up to 50 pounds of force frequently

c.    Exerting up to 20 pounds of force constantly to move objects

          Very heavy work:

a.    Exerting in excess of 100 pounds of force occasionally

b.    Exerting in excess of 50 pounds of force constantly to move objects

c.    Exerting in excess of 20 pounds of force constantly to move objects

Visual requirements necessary to perform the job:

          Far vision:  clarity of vision at 20 feet or more

 X      Near vision:  clarity of vision at 20 inches or less

 X      Mid-range vision:  clarity of vision at distances of more than 20 inches and less than 20 feet

          Depth perception:  the ability to judge distance and space relationships, so as to see objects where and as they actually are

          Color vision:  ability to identify and distinguish colors

          Field of vision:  ability to observe an area up or down or to the right or left while eyes are fixed on a given point

2.  PHYSICAL EFFORT (cont.)

    FREQUENCY

c.        Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):

       Climbing:      Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms.  Body agility is emphasized.  This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.

       Balancing:     Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces.  This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.

       Stooping:       Bending body downward and forward by bending spine at the waist.  This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.

       Kneeling:       Bending legs at knee to come to a rest on knee or knees.

       Crouching:    Bending the body downward and forward by bending legs and spine.

       Crawling:      Moving about on hands and knees or hands and feet.

       Reaching:      Extending hand(s) and arm(s) in any direction.

       Standing:       Particularly for sustained periods of time.

       Walking:       Moving about on foot to accomplish tasks, particularly for long distances.

       Pushing:        Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.

       Pulling:         Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.

       Foot

       Motion:          Using feet to push pedals.

       Lifting:          Raising objects from a lower to a higher position or moving objects horizontally from position to position.  This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.

 X    Fingering:     Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.

 X    Grasping:      Applying pressure to an object with the fingers and palm.

Frequently

Occasionally