Senior Nurse Case Manager

Senior Nurse Case ManagerThe Senior Nurse Case Manager (SNCM) role within the Claims Department is to assist management and the claims team in supporting strategic initiatives and achieving annual claims goals. This position is responsible for applying medical knowledge in reviewing complex workers' compensation claims to determine causal nature of patient's symptoms, medical necessity/reasonableness of treatment, facilitate claimants' return to work (RTW) and propose alternative care arrangements. SNCM assists in development of new medical cost containment programs and projects as well as taking a leadership role in the implementation and ongoing support of these initiatives. The SNCM utilizes competence, positive communication skills, problem solving and conflict resolution techniques. The SNCM demonstrates strong organization and time management skills with the ability to affect change when necessary. This role may execute their essential functions telephonically or as a Field NCM providing in person care and/or coordination.
Field/Hybrid focus:The Field SNCM Manager is responsible for managing the medical care and facilitating return to work for injured employees. The position requires on-site, face-to-face interaction with injured workers, providers, and employers to facilitate appropriate, and timely care that supports recovery and return to work.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
SNCM and FNCMOversee new assignments and make timely initial contacts with all parties.
Reviews patient clinical status and history to determine casual nature of patient's symptoms as related to reported work injuries.
Complete RN template and documentation, to include but not limited to: pertinent medical history, exposure analysis including cost drivers such as anticipated treatment, length of treatment, length of treatment, length of treatment, length of treatment, length of disability and anticipated permanency.
Negotiate and coordinate with employer for early return to work and/or alternative duty based on provider's report on employees' abilities upon receipt of the claim.
Provide oversight of all external nurse case management and external RN task assignments. Document the strategy and anticipated cost benefit to the claim for the assignment. Establish a mutually agreed upon plan of action with the external NCM and a time frame for the completion of that POA.
Applies medical knowledge base during contacts with physicians, therapists, etc. as necessary on any case where prolonged treatment has occurred to assess each case.
Determines the medical necessity/reasonableness of proposed and ongoing treatment as well as inpatient or outpatient hospitalization for each lost-time case.
Conducts case research which may necessitate contacting or meeting with employees, employers, physicians, medical staff members, medical consultants, etc.
Appropriately refers workers' compensation cases not meeting medical criteria to the medical director, designated consultant or independent physician providing supporting case documentation.
Formulates all internal and external correspondence necessary to research and resolve case disputes and case inquiries, contacting providers and involving claims representatives as required. Communicates final decision and subsequent ramifications to claim representatives.
Medically manage claims in multiple jurisdictions.
Close assignment appropriately within internal performance standards.
Training and/or Mentoring nurse case managers with less experience.
Prepare professional presentations for prospective customers.
Assist manager with monthly NCM outcomes including monthly reports and assisting with monthly quality assessment evaluations of Nurse Case Managers if needed.
EDUCATION AND EXPERIENCE for all focuses:Registered Nurse license active and unrestricted required.
Bachelor's degree in nursing (BSN) preferred.
SNCM and Field:Five (5) years of progressive responsibility in injury case management (workers' compensation, group health, auto, etc.).
Three (3) years of active patient or clinical experience as a RN is required.
Three (3) years of workers' compensation case management, rehab, insurance or occupational health experience is preferred.
Field Case Manager experience preferred.
OTHER SKILLS AND ABILITIESKnowledge of clinical care and jurisdictional requirements.
Must possess strong negotiation skills and decision-making ability.
Excellent oral and written communication, customer service, written report preparation, human relations, negotiation and decision-making skills are required.
Proficient in Microsoft Windows Suite.
Must be able to work independently as well as within a team.
Attention to detail and analytical skills required.
Demonstrated leadership abilities are essential.
Knowledge of team building and employee motivation theories with the ability to effectively manage multi-functional employee teams.
Ability to work with and empower others on a collaborativ