Utilization Review / Telephonic Case Mgr (UR/TCM)
2008-09-27 09:59:46(4140)
healthcare
Sacramento - Rancho Cordova area
Needed: One full-time Telephonic Case Manager who will also do some Utilization Review for workmans' compensation cost containment company.
SUMMARY OF RESPONSIBILITIES
The UTILIZATION REVIEW NURSE facilitates the provision of appropriate medical services for workers compensation patients through application of medically accepted treatment guidelines to treatment requests submitted by medical providers. When requested treatment falls within medically accepted treatment guidelines, the Utilization Review Nurse will authorize the treatment, and when the requested treatment does not fall within medically accepted treatment guidelines, the Utilization Review Nurse will collaborate with the requesting physician and/or the AMC Medical Director. The Utilization Review Nurse will follow all legislatively mandated regulations regarding treatment authorizations, modifications and denials.
The TELEPHONIC CASE MANAGER(TCM) is responsible for producing improved claims outcomes for clients through proactive, action-oriented medical management interventions.
The TCM ensures appropriate utilization of medical treatment on workers compensation claims through application of nationally recognized medical treatment guidelines and applicable state workers compensation rules and regulations. The TCM facilitates early return to work of injured workers in attempt to control claims costs through proactive coordination efforts between medical providers, injured workers, employers and claims staff.
The TCM must positively impact claims costs by saving more than they cost. Interventions must be strategic and focused on proper utilization of medical care and early return to work. The TCM must work collaboratively with medical providers, employers, and claims staff to accomplish this mission.
KEY RESPONSIBILITIES OF TCM:
Clearly documents receipt of referral
Conducts initial contacts and medical investigation timely
Conducts ongoing and timely follow-up throughout the case through proactive interventions that move the case towards closure
Utilizes nationally accepted medical treatment guidelines to ensure medical treatment is appropriate
Utilizes medical expertise to assist in compensability determinations
Educates providers and injured workers on return to work, and facilitates return to work process by obtaining work restrictions from medical providers, and communicating and coordinating them to the injured worker and employer
Provides thorough and timely documentation of all TCM activity
Maintains organized and orderly case files
Updates medical treatment plans to address any changes; ensures documentation includes a current treatment plan and plan of action at all times
Refers to Utilization Review appropriately for evaluation of proposed medical treatment
Ensures client specific special account instructions and workflows are followed
Meticulously tracks time and meets company production expectations
Provides ongoing clinical support and acts as a resource to claims staff
Provides customer service to existing and potential AMC TCM clients
Identifies and recommends changes for improved efficiency of TCM program
Ability to utilize all features of the TCM software program
Attends ongoing training courses and stays current on workers compensation regulations and legislation impacting TCM
Provides reports as required by client
Availability for special projects as dictated by AMC management
SKILLS AND ABILITIES
Working knowledge of multiple nationally accepted medical treatment guidelines.
Working knowledge of standard workers compensation regulations
Proven skills in multi-tasking and prioritization of duties
Smoothly adapt to quick changes in priorities
Excellent time management skills
Excellent verbal and negotiation skills
Extremely organized and accurate
Portrays a professional company image to customers, partners and employees
Ability to work with minimal supervision
Excellent written skills
Good computer skills, including use of Microsoft Word and Excel
Good typing and keyboard skills
Ability to work under pressure with occasional heavy task assignments
Facilitate problem solving with clients, prospective clients, colleagues, etc.
Team player with ability to build and foster relationships
QUALIFICATIONS
1+ years workers compensation Case Management experience preferred
2 years clinical nursing experience preferred
2+ years utilization review experience preferred
Experience in reviewing all levels of treatment requests
CURRENT RN or LVN License (Mandatory)
Email resume to:
"Reply to:" address above OR
FDAdmin@alliedmanagedcare.com
Additional questions, please call:
Noor Al-Masri at (916) 563-1911 ext. 332
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