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 ensure 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 recommendations using local, regional, and nationally recognized evidence-based guidelines such as MTUS, ACOEM, MCG, ODG, state-specific treatment guidelines, as well as documentation provided by the PTP.
- Will evaluate for over-utilization of treatment requests inconsistent with evidence-based guidelines and when possible, negotiate with provider to amend or withdraw the treatment request when appropriate.
- Will refer potential non-certified cases to peer clinical reviewers.
- Will perform utilization review on concurrent requests. Follow up when appropriate.
- Arrange peer-to-peer contact with the peer reviewer as needed and as requested by the requesting treating provider.
- Assist in the notification process for the non-certification issued by the physician reviewer.
- 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 writing 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.
- May be required to direct non-clinical tasks to non-clinical staff.
- All Utilization Review for California will be performed in compliance with Labor Code and the California Code of Regulations. Utilization Review in any state will follow and be in compliance with their State Rules & Regulations related to Utilization Review.
- Participate in a quality management program meeting and project for at least 5% of average hours worked.
- Oversight of non-clinician tasks; available to non-clinical administrative staff while performing initial screening.
- Maintain awareness of potential compromise in a patient’s safety for each review. Refer to proper authority.
- Uses plain language to communicate (written and verbal) with injured workers, claims examiners, and clients.
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. The individual must possess an active RN license in California, with a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience
Education and/or Experience:
- Current and valid California RN.
- Minimum of 1 year clinical experience.
- Should be familiar with California Workers’ Compensation; Managed Care experience/Utilization Review experience recommended.
- Completion of IEA CA 10 class within 1 year of employment if no prior workers’ compensation experience.
#J-18808-Ljbffr
