Responsible for managing assigned claims to ensure claims are managed to our Best Practices, including receiving appropriate healthcare in order to return to work and normal activity in a timely and cost effective manner. Caseload may include catastrophic/complex medical/disability cases; lost time and/or medical only claims. This position is a combination of in-house telephonic medical case management and claims representative duties.|
- Contact medical providers and injured workers on assigned lost time cases involving disability and significant medical treatment to determine medical needs.
- Develop medical management strategy and give the providers information necessary to facilitate a return-to-work plan.
- Suggest cost-effective treatment alternatives when appropriate and ensure that injured workers have aggressive treatment plans in place.
- Authorize medical treatment and associated diagnostic testing on assigned claims.
- Assist insured individuals in the development of aggressive return-to-work programs.
- Where appropriate, channel injured workers to network providers.
- Contact employer to initiate modified duty or full return-to-work and/or obtain job description and discuss job modifications required to ensure a prompt return to work.
- Analyze, review, negotiate, and settle Workers’ Compensation claims of varying complexity, in a thorough manner and with minimal supervision.
- Control legal and medical bills/records to ensure savings for the company.
- Make contact with claimants within 24 hours on all lost-time claims.
- Work effectively with doctors, attorneys, insureds, claimants, and associates.
- Participate in prehearing settlement conferences.
- Establish and monitor reserves to adequately reflect the exposure, and make appropriate changes as each file develops.
- Uphold highest level of service orientation toward all customers.
- Assist in agency management by providing feedback to Underwriting.
- Strong communication skills in order to effectively communicate with claimants, medical professionals, employees, claims staff, case management vendors and others.
- Ability to analyze and make sound nursing judgments and to accurately document activities in the claims management system.
- Good negotiation skills to effectively establish target return-to-work dates.
- Knowledge of state, local and federal laws related to health care delivery.
- Personal computer knowledge and proficiency.
- Must have current registered nurse [R.N.] license in the State of Wisconsin and willingness to be licensed in other states as required by law.
- Additional professional certifications, such as CCM, COHN, CRRN, CDMS, and/or CRC.
- Bachelor of Science in Nursing degree from an accredited college or university
- Fluency in Spanish