Job Description

Telephonic Nurse Case Manager Department: Claims Administration & Adjusting Employment Type: Permanent - Full Time Location: Home United States Reporting To: Karen Shaffer Compensation: $65,000 - $76,000 / year Description Our Story Imagine being part of a team that's not just shaping the future but actively driving it. At Davies North America , we're at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors. We're on the lookout for a Telephonic Nurse Case Manager to join our growing team! As a Telephonic Nurse Case Manager, you will be responsible for monitoring, evaluating and coordinating the delivery of high quality, timely, cost-effective medical treatment and other health services under Workers' Compensation law. You will also perform ongoing assessments of the injured employee's recovery to ensure high quality of care, reduce recovery time and minimize the effects of injury. Key Responsibilities Provide specialized telephonic case-management in a Workers' Compensation environment Focus on medical appropriateness of care to injured worker with cost savings by coordination and utilization of all services, ensuring that as soon as medically feasible, return-to-work status is achieved Demonstrate experience in the handling of Workers' Compensation claims according to applicable statutes and rules Facilitate communication between the employee, the employee representative, employer, employer representative, insurer, health care provider, the medical services organization and, when authorized, any qualified rehabilitation consultant, to achieve the goals as identified for that case upon review of the file Clinically evaluate the medical needs of an injured employee after the initial file assessment and incorporate a case management plan to provide quality care in a cost-effective manner Identify barriers to recovery and formulate an action plan to overcome these barriers Provide ongoing assessment of health and medical records Monitor vendor performance, ensuring quality service Develop case-management care plan, track and modify appropriately Appropriately document all data received from contacts and medical records in the computerized system Address the return-to-work capabilities; investigate opportunities for return to work if appropriate; document appropriately in computerized system Manage the file adhering to treatment guidelines and utilization criteria as determined by the state-mandated guidelines pursuant to the specific date of injury, proprietary and nationally published protocols, as well as account requirements, assuring smooth delivery of services to injured workers or third-party claimants Create, edit and/or revise correspondence Evaluate treatment plans and document outcomes, track protocol management for appropriate utilization and delivery of medical services; outcomes will be evidenced by patient satisfaction, appropriate delivery and quality of care and timely recovery per evidenced-based criteria and clinical guidelines, per law for that date of injury Manage the file pro-actively, utilizing all appropriate case management tools Develop alternative treatment plans when necessary Demonstrate the ability to accommodate changes on the case management process for delivery of a more refined, efficient and cost-effective system If applicable, identify the need for Utilization Review procedures to claims, such as triggers that might indicate a potential barrier to recovery; UR tools include physician advisor review, prospective review, concurrent review and retrospective review of bills and reports; communicate the findings determined in utilizing these tools and document appropriately Anticipate health needs during case management process and educate patient and family appropriately; encourage the injured worker to participate in the recovery plan Maintain patient privacy by ensuring that all medical records, case-specific information, and provider-specific information are kept in a confidential manner, in accordance with state and federal laws and regulations Serve as a patient advocate adhering to all legal, ethical, and accreditation/regulatory standards Negotiate fees with providers or channel cases to other vendors as appropriate, with a focus on cost containment, ensuring compliance with applicable statute/rule relevant to the specific date of injury May provide leadership of lower graded staff in the department Perform other duties as needed. Skills, knowledge & expertise RN with 3-5 years clinical experience (medical-surgical, orthopedic, neurological, ICCU, industrial or occupational) Case Management experience and at least 1 year Workers' Compensation experience is required Field Case or Catastrophic Case Management and Utilization Review experience preferred Must possess one of the following certifications: CCRN, CCM, COHN, COHN-S if managing a WC/MCO claim Proof of current State Licensure and eligible for endorsement in all other states Bilingual; fluent English/Spanish preferred Ability to demonstrate strong focus on cost containment to manage cases in most cost-effective way while still ensuring quality medical care Maintain knowledge of current trends, standards and law changes appropriate to the law at the date of injury Must be self-directed and able to work independently Ability to effectively operate a personal computer and related claims and business software Benefits At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes: Medical, dental, and vision plans to ensure your health and that of your family A 401k plan with employer matching to help you build a secure financial future Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment Paid holidays Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones Diversity and Inclusion Davies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard. Davies Public Affairs

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