Nurse Case Manager

AF Group • Kalamazoo, MI • 4d ago

SUMMARY: nnThe Nurse Case Manager (NCM) is responsible for applying medical knowledge in reviewing workers' compensation claims to assess, evaluate, plan, implement and oversee the treatment appropriateness for occupational injuries based upon evidence based guidelines. The NCM utilizes clinical knowledge to evaluate the medical and disability needs of an injured worker against relevant policies, facilitate coordination of the patient's medical treatment and timely return to work. The NCM engages the claimant and physician(s) in providing proactive medical and disability management, working collaboratively with claim handlers in providing focused claim resolution and return to work driven outcomes. The case management process requires a focus on customer service, skills, knowledge of setting appropriate goals and measuring outcomes to effectively ensure optimal outcomes. nnNurse Case Manager, Medical Bill Focus:nnThe NCM, Medical Bill Review applies medical knowledge during the process of reviewing complex workers' compensation medical bills. Review of bills includes the analysis of medical necessity/reasonableness of treatment as well as confirming medical bills and treatment are in concert with utilization review standards. Additionally, evaluates medical claims/bills against relevant policies and statutes to determine claim resolution and communicates decisions to providers. Responsible for monitoring the handling of all health cost disputes to ensure state guidelines are strictly adhered to.nnRESPONSIBILITIES/TASKS: nnThe nurse case manager must be able to demonstrate and be accountable for the standards of practice policies and procedures, quality assurance and the goals of the organization. Also, manage treatment of claimants through the workers' compensation system based on the individual's diagnosis and state workers' compensation regulations.nn n Obtains and reviews patient clinical status and history to determine casual nature of patient's symptoms as related to reported work injuries. n Applies knowledge of age-specific, cultural diversity, psycho/social and developmental issues during the interview process, documentation and intervention with the claimant, their family or significant other. n Determines the medical necessity/reasonableness of proposed and ongoing treatment as well as inpatient or outpatient hospitalization for each lost-time case. n Formulates all internal and external correspondence necessary to research and resolve case disputes and case inquiries, contacting providers and involving claims handlers as required. Communicates final decision and subsequent ramifications to claim handlers. n Presents, discusses and finalizes alternative care and return to work programs with permanency ratings assigned to lost-time cases by medical providers, reinsuring the level of injury and ratings assigned are accurate and consistent with workers' compensation, state, industry and division rating standards and policies, in conjunction with the claim handler. n As it relates to California: Adhere to California Nurse Practice Act, Case Management Code of Professional Conduct and Employee Code of Ethical ConductnNurse Case Manager, Early Detection:nnIn certain circumstances, working with the treating physician to coordinate the initiation of a substance abuse program or detoxification program.n n Uses independent judgment and discretion in identifying and planning strategies to promote effective long term pain management and increase functioning. Works in collaboration with the claimant, claims handler or physicians for changes in the treatment plan as required. Provides claimant/family or significant other with information as needed for workers' compensation services. n Research, utilize and document evidence based guidelines (EBG, ACOEM, and/or ODG) in the evaluation of the current and proposed treatment plan, specifically the use of opioids. n * Seeks consultation from p

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