Senior Medical Case Manager
Broadspire - Oakland, CA

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To provide quality case management services in an appropriate, cost effective manner. Provides medical case management service which is consistent with URAC standards and CMSA Standards of Practice and Quality Improvement Guidelines to patients/employees who are receiving benefits under an Insurance Line including but not limited to Workers' Compensation, Group Health, Liability and Disability.

  • May assist supervisor/manager in review of reports, staff development.
  • Reviews case records and reports, collects and analyzes data, evaluates client's medical and vocational status and defines needs and problems in order to provide proactive case management services.
  • Performs various duties including vocational evaluation, counseling, medical assessment and coordinate return to work.
  • Demonstrates ability to meet or surpass administrative requirements, including productivity, time management, quality assessment (QA) standards with a minimum of supervisory intervention. Facilitates a timely return to work date by establishing a professional working relationship with the client, physician and employer. Coordinates return to work with patient, employer and physicians.
  • May recommend and facilitate completion of peer reviews and IME’s by obtaining and delivering medical records and diagnostic films notifying patients.
  • Manages cases of various product lines of at least 3-4 areas of service (W/C, Health, STD, LTD, Auto, Liability, TPA, Catastrophic, Life Care Planning). Specifically, the case manager should be experienced in catastrophic cases plus 2-3 additional types listed above.
  • Renders opinions regarding case cost, treatment plan, outcome, and problem areas and makes recommendations to facilitate rehabilitation goals and RTW.
  • May review files for claims adjusters and supervisors.
  • May perform job site evaluations/summaries. Prepares monthly written evaluation reports denoting case activity, progress and recommendations in accordance with state regulations and company standards.
  • May obtain referrals from branch claims office or assist in fielding phone calls for management as needed.
  • Maintains contact and communicates with insurance adjusters to apprise them of case activity, case direction or receive authorization for services. Maintains contact with all parties involved on case, necessary for rehabilitation of the client.
  • Travels to homes, health care providers, job sites, and various offices as required to facilitate return to work and resolution of cases.
  • May meet with employers to review active files.
  • Reviews cases with supervisor monthly to evaluate file and obtain direction.
  • May perform other related duties as assigned.

  • Bachelor’s degree in a health-related field is required
  • Five (5) years or more workers’ compensation case management experience in the company or a similar organization and at least 2 years full time equivalent clinical experience
  • Valid RN licensure
  • Minimum of 1 nationally recognized Certification from the URAC list of approved certifications
  • Demonstrated ability to handle complex assignments and ability to work independently
  • Thorough understanding of jurisdictional Workers Compensation statutes
  • Advanced knowledge to exert positive influence in all areas of case management
  • Advanced communications and interpersonal skills in order to conduct training, provide mentorship, and assist supervisor in general areas as assigned
  • Highly skilled at promoting Field Case Management (FCM) products and services internally and externally

In addition to a competitive salary, Crawford offers you:
  • Career advancement potential locally, nationally and internationally. Crawford & Company has more than 700 locations in 70 countries
  • On-going training opportunities through every stage of your career
  • Strong benefits package including matching 401k; health, dental, and life insurance; employee stock purchase plans; tuition reimbursement and so much more.
Crawford & Company participates in E-Verify and is an Equal Opportunity Employer. M/F/D/V

Crawford & Company is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at Crawford via-email, the Internet or in any form and/or method without a valid written Statement of Work in place for this position from Crawford HR/Recruitment will be deemed the sole property of Crawford. No fee will be paid in the event the candidate is hired by Crawford as a result of the referral or through other means.

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