RN- Nurse Case Manager

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 of assignment.
• Initial contacts (employee, employer, Primary Care Physician) and documentation are 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.
• 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, according to state specific rules and regulations.*
• All claims assigned are triaged within 24 hours of assignment.
• Initial contacts (employee, employer, Primary Care Physician) and documentation are 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.
• 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, according to state specific rules and regulations.*
• 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 MTUS, ACOEM, MCG, ODG, state specific treatment guidelines, as well as documentation provided by the PTP. *
• Will …