The Utilization Management Case Manager performs initial and on-going clinical assessment and evaluation needed for treatment of work related injury and illness. The Utilization Management Case Manager coordinates resources with on-going monitoring and creates flexible, cost-effective options for ill or injured individuals on a case-by-case basis to facilitate quality individualized treatment goals, including timely return to work if appropriate.
Essential Job Duties:
1. Assess resource utilization and cost management, the diagnosis, treatment, prognosis, short and long term goals.
2. Develops and maintains current case action plans on assigned caseload.
3. Identify opportunities for intervention to return the injured worker at the earliest and safest opportunity.
4. Address C-9 treatment requests appropriately
5. Negotiate all possible treatment denials with providers
6. Follows established policies and procedures.
7. Utilizes national treatment guidelines to support clinical decision making.
8. Coordinate Independent Medical Evaluations.
9. Provide assessment, planning, implementation, and evaluation of patient's progress.
10. Evaluate patient's treatment plan for appropriateness, medical necessity, and cost effectiveness.
11. Implement care such as negotiating and coordinating the delivery of durable medical equipment and nursing services.
12. Devise cost-effective strategies for medical care.
13. Any BR/NC treatment requests researched for appropriateness utilizing multiple resources, UCR, then email BWC med policy for approval
14. Completes C-9 Presumptive Allowance process
15. Performs claim re-activation reviews.
16. Documents treatment decisions in claim systems
17. Works well in team environment, and educates non-clinical staff when opportunity presents.
18. Required to read extensively.
19. Required to prepare organized reports within a specified timeframe.
20. Required to use telephone extensively.
21. Sends letters, emails, and/or faxes as needed to manage cases
22. Minimum Quality Assurance score is 95%
23. Complies with HR policy regarding regular and consistent attendance.
24. Comply with all safety rules and regulations during work hours in conjunction with the Injury and Illness Prevention Program (IIPP).
25. Additional duties as required.
Above average human relations, verbal and written skills in order to communicate effectively and obtain cooperation from all corporate levels, providers, injured workers and the BWC.
Strong cost containment background, such as utilization review or managed care preferred.
Ohio workers’ compensation case management knowledge preferred.
Current certification as a case manager from the URAC approved list of certifications:
o CCM, Certified Case Manager
o CDMS, Certified Disability Management Specialist
o CMAC, Case Management Administrator, Certified
o CMC, Case Management Certified
o CRC, Certified Rehabilitation Counselor
o CRRN, Certified Registered Rehabilitation Nurse
o COHN, Certified Occupational Health Nurse
o RN,C Registered Nurse Case Manager
o RN,BC Registered Nurse Case Manager
CorVel Corporation - 14 months ago
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CorVel is a national provider of industry leading risk management solutions to employers, third party administrators, insurance companies...