Company Description

Our Client provides Utilization Review/ Medical Management services to its clients. Cases are reviewed by a licensed RN or LPN. The Nurse Case Reviewer reports to the UR Department Manager for clinical activities.

Job Description

Job Responsibilities:

Is knowledgeable and compliant with all regulatory and statutory regulations that pertain to New York State Workers’ Compensation Law including Medical Treatment Guidelines, as well as a familiarity with ERISA and HIPAA confidentiality requirements.
Provides and facilitates utilization review, continued stay reviews and utilization management of all cases as necessary, based on clinical experience and recognized guidelines.
Collaborates telephonically with workers' compensation patients, employers, providers, and claims adjusters to coordinate and assure proper delivery and oversight of medical and disability services and to expedite successful outcomes for recovery and timely return to work.
Collaborates with Medical Directors as necessary to determine medical necessity on requests for treatment.
Performs pre-certification/responds to variance requests for prescribed treatment in a timely manner by gathering relevant data and information from provider(s), the injured employee, and the employer.
Interacts telephonically with employers, employees/patients and provider(s) to determine medical status, type of care needed (surgery, hospitalization and/or physical therapy etc.) and future care needs.
Assesses and identifies barriers to recovery; determines goals, objectives, and potential treatment alternatives.
Facilitates and expedites discharge planning when necessary.
Maintains accurate records of individual cases.
Ensures each case provides optimal medical care that is cost effective.
Answers provider calls and assists with answering call-center overflow calls as necessary.
Is kind, caring, sympathetic and positive with all customers and fellow employees.
Adheres to established quality assurance standards and all of our policies and procedures.
Discusses and documents any concerns, complaints and/or issues with direct supervisor or the Director of the department or Chief Medical Officer if the UR manager is not available.
Other assigned duties as required.
Participates in QA activities for up to 10% of employed time.

Qualifications

Essential Qualifications:

Currently licensed Registered Nurse (RN) or Licensed Practical Nurse (LPN) with licensure in their state of employment (New York State).
Must maintain current licensure(s) and specialty certifications that are relevant to this position; CCM is encouraged.
Bachelor’s degree preferred.
Minimum of 4 years experience in a clinical environment required.
Previous workers’ compensation case management experience required.
Previous experience in utilization review/medical management preferred.
Strong skills in medical assessment/medical record review.
Excellent customer service skills.
Ability to define and solve problems, collect data, establish facts and make effective decisions a must.
Must be detail oriented and have strong organizational and time management skills, and the ability to work independently
Ability to work proficiently on a computer (PC) with working knowledge of Microsoft Office, especially Word, Excel and Outlook.
Ability to work in a database environment a plus.

Additional Information

Submittal Instructions:

If you meet the requirements and are looking for a work environment that values individual contribution and teamwork, let us know. Please send that information, along with your current resume in Word format to: contactus@2HireTalent.com