General Description: Manages medical aspects of workers compensation and disability claims for Third Party Administration (TPA) accounts by coordinating with patients, physicians, other health care providers and employers to facilitate positive patient outcomes, timely return to work if applicable and efficient claims resolution.

 

Responsibilities:

Manages activities of workers compensation and disability claims, case management and utilization review according to established policies and procedures and applicable legal and regulatory guidelines. Manages ongoing managed care activities, including case management of medical aspects of workers compensation and disability claims for TPA accounts by coordinating with patients, physicians, other health care providers and employers to facilitate positive patient outcomes, timely return to work if applicable and efficient claims resolution and utilization review, gathering demographic and clinical information on inpatient admissions and outpatient treatment, certifying the medical necessity of the services and assigning appropriate length of stay and other treatment plans. Presents case management and utilization review information and overviews to prospects and clients as needed. Assists adjuster with complex medical aspects as necessary. Resolves escalated issues and problems by conferring with staff, management, other internal departments, outside contacts and clients as necessary. Performs case management and other activities as workload requires. Responds to requests from insurance carriers, medical personnel, attorneys and others. Assesses internal and external customer needs and manages activities to ensure services are delivered in the most efficient way possible. Reviews and evaluates medical claim activities on a regular basis, ensuring that established policies and procedures are being followed. Ensure ongoing department communications with sales, claims and management as well as other Company departments to exchange account and other information. Maintains knowledge of current developments in the managed care industry, including regulatory issues and guidelines changes. Participates in special projects and performs additional duties as required. Contributes to a positive, ethical and respectful working environment and communicates openly with others. Models Company culture both internally and externally.  

Knowledge, Skills and Abilities:

4-year nursing degree or the equivalent combination of education and work experience required. Masters degree in business, healthcare or other related field preferred. A 5 to 10 years workers' compensation and disability case management experience required. Excellent understanding of managed care industry practices, including medical case management, utilization review and related legal and regulatory guidelines. Strong clinical background in orthopedics, neurology or rehabilitation. Highly organized, with ability to manage work involving large client volume. Project management skills. Strong understanding of managed care technology applications. Excellent communication skills, both verbal and written. CCM, CRS or CDMS certification required. State licensing in jursdication handled Superior written and oral communication skills. Ability to work well in a team environment. Must have strong analytical thinking and problem-solving skills. Strong organizational skills required.