Nurse - Claim Representative Workers’ Compensation
Secura - Appleton, WI

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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.

Qualifications:

Required:
  • 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.
Preferred:
  • 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

Secura - 18 months ago - save job - block