Determines the medical necessity/reasonableness of proposed and ongoing treatment as well as inpatient or outpatient hospitalization for each lost-time case.
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.
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.
As it relates to California: Adhere to California Nurse Practice Act, Case Management Code of Professional Conduct and Employee Code of Ethical Conduct
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.
EMPLOYMENT QUALIFICATIONS
Registered Nurse license active and unrestricted required. Bachelor’s degree in Nursing (BSN) preferred. Continuous learning required, as defined by the Company’s learning philosophy. Certification or progress toward certification is highly preferred and encouraged.
EXPERIENCE
Three years active patient or clinical care experience as a Registered Nurse required. Three years workers’ compensation case management, occupational health, rehabilitation or insurance experience preferred.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED
Knowledge of clinical care and jurisdictional requirements.
Demonstrates the ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction.
Strong time management skills.
Excellent oral and written communication, customer service, written report preparation, human relations and decision making skills are required.
Demonstrates use of critical thinking, attention to detail, sound clinical judgment and assessment skills for decision making.
Proficient with computer and Microsoft Windows Suite.
Demonstrates courteous, professional demeanor and team spirit and the ability to work in a collaborative, effective manner.
WORKING CONDITIONS
Work is performed in an office setting with no unusual hazards. Minimal travel.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.
PAY RANGE
Actual compensation decision relies on the consideration of internal equity, candidate’s skills and professional experience, geographic location, market and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $63,000 and $90,400.
