Under general supervision, serves as a member of a customer service team; provides medical direction (e.g. complicated cases involving co-morbidity factors, clinical complications, catastrophic claims) that require continuous medical case management strategies (e.g. assessment, monitoring, intervention); serves as the medical resource on team regarding medical evidence & policy; responds to inquires from Service Office staff regarding medical evidence & information; advises claims staff in obtaining objective medical evidence to support BWC findings & determinations; serves as liaison with medical community to obtain reports, clarify issues, & determine appropriate ICD codes & diagnoses; reviews & analyzes subjective & objective evidence for medical indicators of conditions not caused by or arising out of employment; identifies & reports claims situations where further clarification &/or development of medical evidence is required; identifies claims situations where there is a need for physician exam &/or review (e.g. complicated medical issues involving request for additional allowance or continued compensation as requested by CSS); assists CST in the review process (e.g. appropriateness of exam, selection of physician specialty) for physician exams & file reviews; reviews & evaluates diagnosis coding on ICDM-9 & communicates findings to appropriate parties; performs medication utilization reviews in consort with physicians & CST to determine continuing reimbursement for prescription medication(s); serves as active participant in the assessment, planning & evaluation of services as part of a multidisciplinary approach with CST, MCOs, Rehab & employers to assist IW to RTW or to attain an optimal level of independence (i.e. 'wellness') Performs quality assurance of medical reports to confirm a quality independent exam process; reviews format, presence of objective & subjective findings, relevant conclusions, compliance with BWC policy, guidelines & established medical protocols & timeliness of exams & reports; communicates with physicians, providers, & other interested parties (e.g. injured worker, employer, attorney) by written, phone, & on-site communication regarding BWC medical claims-management issues. Authorizes services requested by outsource vendors in catastrophic claims according to BWC criteria; serves as facilitator &/or liaison between claims staff & outsource vendors to prevent delays & errors & interpret &/or explain medical policy & guidelines for catastrophic claims. Conducts on-site (e.g. provider, work-site, injured workers' home) interviews, observations, & assessments to facilitate quality BWC claims determinations as needed: conducts yearly on-site nursing or file review assessments to determine eligibility for continuation of existing caregiver services; provides requested medical documentation for medical service vendors, physicians, & claims staff for appropriate & timely authorization.
Performs related duties as required (e.g. prepares & delivers speeches & reports designed to educate, clarify, reinforce, communicate, & provide feedback to other BWC divisions & interested parties [e.g. employers, providers, legal & injured worker groups], provides training on medical issues to claims staff &/or new medical personnel).
Unless required by legislation or union contract, candidates can expect to be paid at the lowest rate of the salary range associated with this position.
Current & valid license to practice professional nursing as Registered Nurse (i.e., R.N.) in Ohio as issued by Board of Nursing pursuant to Section 4723.03 of Ohio Revised Code;
AND 6 mos. exp. as licensed Registered Nurse.
Major Worker Characteristics:
Knowledge of: nursing; federal & state laws; BWC policies & procedures*; case management strategies; ICD & ICDM9 codes; interviewing; public relations; medical techniques, procedures, & definitions; employee training.
Ability to: interpret diagnoses, assess limitations & write accurate medical reports based on claim data; read & comprehend medical charts, manuals & journals; medical policy & guidelines; handle routine inquiries from & contacts injured workers, employers, physicians, attorney’s, government officials, providers or representative & general public; independently review medical bills to analyze costs & deem appropriateness; explain medical policy & guidelines; prepare & deliver speeches before specialized audiences & general public.
(*) Developed after employment.
**This position does not offer supplemental or shift differential pay.**
This position requires a current & valid license to practice professional nursing as registered nurse (i.e. R.N.) in Ohio as issued by Board of Nursing pursuant to Section 4723.03 of Ohio Revised Code.
In order to remain in this classification after employment, incumbent is required to renew license to practice as a registered nurse on a biennial basis.
The final external applicant selected for this position will be required to submit to urinalysis prior to appointment to test for illegal drug use. An applicant with positive test results will NOT be offered employment.
Position requires travel therefore, persons occupying this position must be able to provide own transportation, &/or legally operate a state owned vehicle.
EDUCATIONAL TRANSCRIPT REQUIREMENT:
Official educational transcripts are required for all post-high school educational accomplishments where the applicant is seeking to meet minimum qualifications and/or position-specific minimum qualifications by way of education. Applicants who are not employed by BWC must submit an official transcript at the time of interview or the applicant will be eliminated from further consideration. Applicants who are BWC employees must have an official transcript on file in the Personnel Office by the deadline date of the job posting. Please note that a transcript is only considered “official” if it is an original copy from the educational institution containing an institutional watermark, ink stamp, or embossed (textured) stamp. Transcripts printed from the institution’s website will not be accepted.
State of Ohio - 2 years ago
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