Case Manager II, RN - Pharmacy
PMA Capital Corporation - New York

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Function as an expert resource to provide intervention on Worker’s Compensation files relating to all aspects of Pharmaceutical intervention. Application of Clinical Guidelines utilized to assist in establishing appropriate treatment patterns that inhibit possible long term medication dependency for complex files. Position requires active management of files to intervene as required to achieve best claim outcome and needs for individual claimant as well as providing training to extended Claim and Case Management teams on effective Pharmacy management principles.

Essential Functions:
  • Assessment of medical treatment requested by the provider to correlate to established guidelines
  • Collaborate with Claims Adjuster to assess current file status and impact of treatment request on Claim outcome
  • Provide ongoing training, education and job aides to the Claims and Managed Care Department to assist in Pharmacy management
  • Educate, facilitate and support Pharmacy tools as available through PBM to maximize utilization of program and achieve optimum outcomes
  • Establish agreed upon time line with treating providers at initial medication dispense to assure duration of medication treatment does not exceed guidelines
  • Respond to point in time alerts on Claim files to provide intervention when medication regime approaches dose, duration and frequency that exceeds treatment guidelines
  • Facilitate Drug Utilization Advisory (Review) to obtain Pharmacist recommendations on therapeutic alternatives to current medication regime
  • Coordination of Peer to Peer process when appropriate through facilitation of communication between medical specialties
  • Provide Claims with recommendations for appropriate specialty, resource and value driven exam objectives for Independent Medical Exams
  • Applies state Medical Treatment Guidelines relating to Pharmacy parameters in order to maximize jurisdictional opportunity to manage medication use
  • Recommends Utilization Review process dependent on jurisdictional opportunity
  • Establish and coordination of weaning protocols with Pain Management and all active treating providers
  • Coordination of face to face provider collaboration utilizing appropriate field Case Management resources when written or telephonic communication has been exhausted
  • Recommends and facilitates drug testing utilizing network services in coordination with treating providers. Purpose is to validate medication is taken as prescribed and no additional substances are present that are contraindicated in treatment
  • Support and encourage the benefit of narcotic contracts in coordination with treating providers. Establishes guidelines and parameters for the utilization of narcotic medication regime that reduces the chance of long term dependency through a structured approach. Also, assists in the weaning process in those cases where dependency on the medication has occurred.
Qualifications:
  • Degree in Nursing, Healthcare and or Occupational Medicine
  • Active Registered Nurse (RN) license in current state of residence. Additional state specific licenses may be required in future
  • Certified Case Manager (CCM), Certified Disability Management Specialists (CDMS), Certified Rehabilitation Registered Nurse (CRRN), and/or Certified Occupational Health Nurse (COHN) professional designation(s) preferred.
  • Minimum of three years experience in a clinical facility in orthopedics, neurology, critical care, emergency trauma, general surgery, rehabilitation, physical medicine and/or occupational health.
  • Knowledge and solid understanding of all regulatory requirements for assigned jurisdictions related to worker's compensation medical management.
  • Demonstrated knowledge of current medical treatments and transitional work practices encountered in worker's compensation cases.
  • Proven technical proficiency through timely consistent execution of best case management practices.
  • Computer literacy in the use of email MS Office Product Suite (i.e. Word Excel), proprietary PMA systems and internet queries for research.
As a leader in the property and casualty insurance industry with multiple locations, our clients choose PMA Companies because we understand that excellent service begins with our employees. Our working relationships with clients are marked by professionalism, execution and accountability and our company culture is centered on teamwork. This combination has created a supportive work environment that encourages personal and professional growth.

We offer a very competitive compensation package including a 401(k) with dollar for dollar match on the first 5% of salary, tuition reimbursement and much more!

PMA Capital Corporation - 15 months ago - save job - block
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