The Northern California Division’s Workers’ Compensation Department, located in Pleasanton, California has an opening for a Medical Nurse Case Manager.
Licensed registered nurse.
BSN strongly preferred.
Certification in one of the following: CCM, COHN, CPDM, CRRN or equivalent.
Minimum five years of professional clinical practice - Ortho, Rehab, ICU /ER, or Occupational Health with 3 years in a case management role.
Knowledgeable in workers' compensation - medical and disability case management and/or utilization review / utilization management practices and procedures.
Extensive knowledge of medical and pharmaceutical terminology.
Computer proficiency with basic claims system and Microsoft Office, including Word and Excel.
Successful experience in conflict management and negotiations.
Self-motivated, excellent oral and written communication skills, documentation and follow-up.
Knowledge of related employment benefits (ADA, FMLA, state disability legislation, LTD, SDI, group health benefits) and how they interact with workers compensation benefits.
High degree of initiative; proven team player.
Key Responsibilities include, but are not limited to:
Conduct medical and disability case management consistent with professional standards and best practices for management of occupational and/or non-occupational illness /injury. (Assessment, Intervention, Evaluation).
Facilitate medical access for the injured worker to the highest quality medical services utilizing appropriate provider networks.
Communicate with employee, physician and employer.
Effectively collaborate with customer and claims team partners.
Ongoing analysis of cost containment program process and outcomes in order to maximize direction of injured worker to quality medical care.
Coordinate medical care services.
Execute case management assignments based on clearly defined referral criteria.
Document use of best practice references such as standardized disability duration guidelines and medical management protocols.
Advises and make recommendations regarding medical and disability management.
Conduct medical technical and medical claims procedure orientation for new hires in the department.
Organize and conduct training sessions for the workers' compensation claims management team.
Manage and support multiple projects in a fast-paced environment.
Salary and range will be commensurate with experience and qualifications.
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