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Healthcare Case Management Specialist

2 months ago

Modesto, California, United States Crawford & Company Full time

Commitment to Excellence:

Position Overview:

  • Balanced Work-Life Integration
  • Incentive Program Offered Monthly
  • Complimentary Continuing Education Units for Licensure
  • Reimbursement for Licensure and National Certifications
This role is primarily remote, with occasional travel required for field case management within a designated region. Preferred qualifications include national certifications such as CCM, CRC, COHN, or CRRC. A valid RN degree is mandatory.
Experience in Workers Compensation Case Management is advantageous. The primary objective is to deliver efficient case management services in a cost-effective manner.

Provides comprehensive medical case management services adhering to URAC standards, CMSA Standards of Practice, and Broadspire Quality Assurance (QA) Guidelines for patients/employees receiving benefits under various insurance lines, including but not limited to Workers' Compensation, Group Health, Liability, Disability, and Care Management.

Depending on federal, state, or local regulations, this position may necessitate full vaccination against COVID-19, which will be discussed during the interview process.

Key Responsibilities:

  • Assess case documentation and reports, gather and interpret data, evaluate the medical status of injured or disabled individuals, identify needs and barriers to medical case resolution, and provide proactive case management services.
  • Offer insights regarding case expenses, treatment strategies, outcomes, and challenges, while making recommendations to achieve case management objectives, including return-to-work (RTW) plans.
  • Exhibit the ability to fulfill administrative duties, including productivity, time management, and QA standards, with minimal supervisory oversight.
  • Conduct job site evaluations/summaries to support the case management process.
  • Foster timely return-to-work dates by building professional relationships with injured workers, physicians, and employers, coordinating RTW efforts.
  • Maintain communication with claims adjusters to keep them informed of case developments, directions, or to secure service authorizations. Engage with all parties involved in the case as necessary.
  • May retrieve records from branch claims offices.
  • May review files for claims adjusters and supervisors to ensure appropriate referrals for case management services.
  • May meet with employers to discuss active files.
  • Facilitate referrals for peer reviews and Independent Medical Examinations (IMEs) by obtaining and delivering medical records and diagnostic images, while notifying the injured worker/disabled individual and consulting with physicians.
  • Utilize clinical expertise and medical resources to analyze medical records and test results, providing assessments accordingly.
  • Travel may comprise approximately 70% of work time, visiting homes, healthcare providers, job sites, and various offices as needed to facilitate RTW and case resolution.
  • Meet monthly production and quality assessment (QA) standards to ensure a high-quality output.
  • Review cases with a supervisor monthly to evaluate files and receive guidance.
  • Uphold the Crawford and Company Code of Business Conduct consistently.
  • Demonstrate exceptional customer service and respect for clients, colleagues, and management.
  • Independently approach problem-solving by effectively utilizing research and resources.
  • May perform other related duties as assigned.

Qualifications:

  • An Associate's degree or relevant coursework/certification in Nursing is required; a BSN degree is preferred.
  • A minimum of 1-3 years of diverse clinical experience and one of the following:
  • Certification as a case manager from an URAC-approved list of certifications (preferred);
  • A registered nurse (RN) license.
  • At least one National Certification (CCM, CDMS, CRRN, or COHN) is preferred. If not obtained, a plan to take the certification exam within the next 36 months is required.
  • National certification must be achieved to attain Senior Medical Case Management status.
  • Compliance with state requirements regarding national certifications is essential.
  • Based on federal, state, or local law, this position may require full vaccination against COVID-19.
  • Active RN home state licensure in good standing without restrictions from the State Board of Nursing.
  • Must meet specific criteria to provide medical case management services.
  • National certification must be obtained to reach Senior Medical Case Management status.
  • Travel may constitute approximately 70% of work time.
  • A valid driver's license in the state of residence is required.
  • General knowledge of case management practices and the ability to quickly learn and apply workers' compensation/case management products and services.
  • Strong oral and written communication skills to effectively facilitate return-to-work solutions within a matrix organization and ensure timely, quality documentation.
  • Excellent analytical and customer service skills to aid in resolving case management challenges.
  • Basic computer proficiency, including familiarity with Microsoft Office products and Lotus Notes.
  • Proven ability to establish collaborative working relationships with claims adjusters, employers, patients, attorneys, and all levels of employees.
  • Demonstrated ability to gather and analyze data and develop plans to enhance trends, processes, and outcomes.
  • Exceptional organizational skills, evidenced by the ability to manage multiple tasks simultaneously.
  • Demonstrated leadership capabilities with a foundational understanding of supervisory and management principles.

About Crawford & Company:
At Crawford, we understand that a claim is more than just a number — it represents a person, a child, a friend. By assisting in restoring their lives, we contribute to revitalizing our community, one claim at a time.

Our employees are empowered to grow, encouraged to take initiative, and inspired to innovate. Our industry-leading team develops new solutions for the sectors and clients we serve. We seek the next generation of leaders to embark on this journey with us.

We operate in over 70 countries and communicate in numerous languages, reflecting the diverse fabric of the audience we serve.

Despite our extensive reach, we proudly function as One Crawford:
united in purpose, vision, and values. Discover more about us. When you join Crawford, you become part of the One Crawford family. Our comprehensive compensation plans offer our employees much more than just a competitive salary:
Performance-based pay and incentive plans
Benefit programs that promote financial, physical, and mental well-being
Training initiatives that foster continuous learning and career advancement while enhancing job performance
Sustainability efforts that contribute to the communities in which we live and work

We cultivate a culture of respect, collaboration, entrepreneurial spirit, and inclusion. Crawford & Company participates in E-Verify and is an Equal Opportunity Employer.

M/F/D/V Crawford & Company does not accept unsolicited assistance from search firms for this employment opportunity.

All resumes submitted by search firms to any employee at Crawford via email, the Internet, or in any form and/or method without a valid written Statement of Work in place for this position from Crawford HR/Recruitment will be considered the sole property of Crawford.

No fee will be paid if the candidate is hired by Crawford as a result of the referral or through other means.

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