Office based telephonic medical case management with emphasis on early intervention, return to work planning, coordination of quality medical care on claims involving disability and medical treatment as well as in-house medical reviews as applicable to claim handling laws and regulations. Responsible for helping to ensure injured parties receive appropriate treatment directly related to the compensable injury or assist claim handlers in managing medical treatment to an appropriate resolution.
Contact medical provider and injured parties on claims involving medical treatment and /or disability to coordinate appropriate medical care. Develop medical management strategy and give the provider information necessary to facilitate a return to work plan on claims requiring disability management. Responsible for ongoing evaluation of treatment and return to work plan, within established protocols.
Work with medical providers and suggest cost effective treatment alternatives, when appropriate. Help ensure that all injured parties are on an aggressive treatment plan. Authorize medical treatment and associated diagnostic testing on assigned claims as allowed by state or policy jurisdictions. For nurses handling Workers Compensation Claims, perform Utilization Review according to established guidelines. Utilize physician advisor program.
Proactively manage the medical expenses by partnering with specialty resources to achieve appropriate claim outcomes (SIU, Legal, Risk Control, Disability Management, IME and Peer Review vendors, Major Case, etc.)
Obtain medical records from providers telephonically during initial contact, and follow up with written correspondence if necessary. Discuss medical information and disability status with claim handler and integrate into overall strategy to ensure appropriateness of indemnity payments. Provide technical assistance and act as a resource for claim handling staff.
Contact employer to initiate modified duty or full return to work. Obtain job description and discuss job modifications required to ensure a prompt return to work. Medical Case Manager will work with employer, injured party, provider and claim handler to expedite return to work.
Identify cases requiring task assignments to field case managers, discuss with supervisor for assignment to Medical or Vocational Case Manager, or vendor.
Document all contacts and outcomes related to case activity in system. Submit billing reports on all activities per established guidelines.
Provide feedback to Preferred Provider Network regarding provider nominations and experience with providers.
Comply with established Best Practices
Perform other duties as required.
EDUCATION/COURSE OF STUDY:
Registered Nurse or other qualified health professionals.
CDMS, CRC, CCM, CRRN desirable
Disability case management experience preferred.
Appropriate license per state regulation
Very strong oral and written communication skills.
Good computer skills
Strong clinical background.
Knowledge of medical causation and relatedness, as well as use of medical treatment protocols and physician advisor/peer review programs.
Understanding of Workers Compensation laws or Auto First Party Medical preferred.
Nursing skills and knowledge
Customer Focus/ Communication
Use of Technology
Travelers is an equal opportunity employer. We actively promote a drug-free workplace.
Travelers Co - 2 years ago