Clinic Nurse, Medical Case Manager – Workers Compensation

Role Overview

• Meet with injured employees face to face following office visits at a provider's medical facility to assist with the claim process and ensure compliance with their medical treatment plan.
• Contact customer, medical provider and injured parties on claims involving medical treatment and /or disability to coordinate appropriate medical care and return to work.
• Develop strategies to facilitate an injured employee's return to work and achieve maximum medical improvement.
• Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim.
• Coordinate with medical providers to ensure the injured employee is actively participating in a viable treatment plan.
• Evaluate medical treatment requests to ensure that they are reasonable and necessary based upon jurisdictional guidelines.
• Engage specialty resources as needed to achieve optimal resolution (Dial-a-doc, physician advisor, peer reviews, MCU).
• Partner with Claim Professional to provide medical information and disability status necessary to create an overall strategy to achieve an optimal outcome.
• Utilize internal Claim Platform Systems to manage all claim activities on a timely basis.
• Utilize Preferred Provider Network per jurisdictional guidelines.
• Partner with Claim Professional to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves.
• Submit accurate billing documentation on all activities as outlined in established guidelines.
• Participate in Telephonic and/or onsite File Reviews.
• Respond to inquiries
• oral and written.
• Keep injured worker apprised of claim status.
• Perform other duties as assigned.

Requirements

• RN or LVN Disability case management experience.
• Prior clinical experience.
• Familiarity with URAC standards.
• Analytical Thinking: Identifies current or future problems or opportunities; analyzes, synthesizes and compares information to understand issues; identifies cause/effect relationships; and explores alternative solutions that support sound decision-making.
• Communication: Expresses, summarizes and records thoughts clearly and concisely orally and in writing by applying proper content, format, sentence structure, grammar, language and terminology.
• Negotiation: Intermediate ability to understand alternatives, influence stakeholders and reach a fair agreement through discussion and compromise.
• General Insurance Contract Knowledge: Ability to understand policies and contracts, as they apply to policy conditions.
• Principles of Investigation: Intermediate investigative skills.
• Value Determination: Basic ability to determine liability and assigns a dollar value based on damages claimed and estimates, sets and readjusts reserves.
• Legal Knowledge: Basic knowledge, understanding and application of state, federal and regulatory laws and statutes, rules of evidence, chain of custody, trial preparation and discovery, court proceedings, and other rules and regulations applicable to the insurance industry.
• Medical knowledge: Thorough knowledge of the nature and extent of injuries, periods of disability, and treatment needed.
• WC Technical: intermediate ability to demonstrate understanding of WC Products and ability to apply available resources and technology to manage treatment plans and assist with claim resolution.
• Customer Service: Advanced ability to build and maintain productive relationships with our insureds and deliver results with optimal outcomes.
• Teamwork: Advanced ability to work together in situations when actions are interdependent and a team is mutually responsible to produce a result.
• Planning & Organizing: Advanced ability to establish a plan/course of action and contingencies for self or others to meet current or future goals.
• Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Clinical Research Counselor (CRC), or Certified Rehab Registered Nurse (CRRN).

Benefits

• Health Insurance : Employees and their eligible family members – including spouses, domestic partners, and children – are eligible for coverage from the first day of employment.
• Retirement: Travelers matches your 401(k) contributions dollar-for-dollar up to your first 5% of eligible pay, subject to an annual maximum.
• Pension Plan that is 100% funded by Travelers.
• Paid Time Off: Start your career at Travelers with a minimum of 20 days Paid Time Off annually, plus nine paid company Holidays.
• Wellness Program: The Travelers wellness program is comprised of tools, discounts and resources that empower you to achieve your wellness goals and caregiving needs.
• Access to free professional counseling services and health coaching.
• Volunteer Encouragement: Travelers has a Matching Gift and Volunteer Rewards program that enables you to give back to the charity of your choice.