Nurse Case Manager

Employers Holdings, Inc. Charlotte, NC
General Summary

Our Nurse Case Manager I performs duties to provide telephonic proactive care management services promoting patient restoration of health and reduction of disability, and maintain a caseload of serious to complex cases for care management in applicable states as indicated. Work is performed under minimal direction within a computer-based environment.

Essential Duties and Responsibilities:

* Provides telephonic proactive care management services and has responsibility for cases assigned; Provides specialized medical expertise on serious to complex claims to assist Claims Adjuster with reserve estimates as needed. Notifies Claims Adjuster of any status change.

* Acts as a coach/mentor and resource for Licensed Practical Nurses and technical staff.

* Assigns tasks to the Care Management Technician.

* Determines if recommendations for medical care compare with the company approved best practice standards as well as utilization of nationally recognized clinical guidelines such as ACOEM, Official Disability Guidelines and Medical Disability Advisor.

* Understands URAC standards as they apply to utilization management and applies this understanding in the case/care management process.

* Performs Utilization Review (UR) by authorizing services based on company Medical Policy and approved best practice standards, including selection of appropriate medical provider from contracted provider network for referrals, medical treatment, 2nd opinions, expert medical opinions, etc., as well as appropriate referral to Medical Directors/Advisors for non-certification/dispute resolution.

* Functionally understands and proactively applies case management and nursing knowledge and processes including assessment, planning, implementation, coordination and evaluation (APICME) processes to all assigned care managed cases. Utilizes appropriate designated panel providers as per provider contracted networks.

* Communicates and documents medical care management needs/rationale based upon company approved best practice standards to Clients, Providers, and Insurer.

* Implements proactive interventions to achieve client goals and objectives in collaboration with Provider, Employer, Claims Adjuster, and Injured Worker. Documents all specific case activities i.e. all aspects of care management efforts, discussions and variances with Injured Workers, Employers, Providers, Examiners, etc. in the claims system.

* Develops and implements the proactive case management plan based on the medical treatment plan per the treating physician, in conjunction with company approved Medical Policy and best practice standards, length of disability (LOD), temporary and permanent limitations, obtaining job description in collaboration with the Claims Adjuster and discharge plan assessment(s) utilizing company approved best practice standards/guidelines as per ACOEM, Official Disability Guidelines, and Medical Disability Advisor.

* Confers with or refers cases to Medical Directors/Advisors for review when indicated.

* Orchestrates and supports Early Return to Work (ERTW) initiatives by assisting Claims Adjuster, Injured Worker and Provider. Coordinates with Providers to expedite release to return to work (RRTW).

* Facilitates collaborative joint action plans, to include medical aspect/plan with Claims Adjuster.

* Directs Injured Worker to other resources for non-industrial issues.

* Evaluates Injured Worker compliance with care plan and ERTW.

* Provides triage services on cases as designated.

* Maintains all required nursing license and certifications as applicable by completing continuing education units as required by respective State Boards of Nursing and/or credentialing organizations as applicable, and practices within their scope of licensure and certification.

* Adheres to all applicable state laws and regulations.

* Respects and observes Injured Worker's right to confidentiality at all times.

* Maintains confidentiality of all data and records.

* Reviews and responds to incoming mail, emails, telephone calls, and fax transmissions from providers and injured workers, related to caseload. Takes actions required to respond within regulations and policy.

* Conducts business at all times with the highest standards of personal, professional and ethical conduct.

* Ensures timely compliance with all policy and procedures as well as jurisdictional statutes.

* Establishes and maintains ongoing professional communications with all appropriate parties, internal and external.

* Other duties may be assigned.

Job Requirements:

* Bachelors (or higher) degree in a health or human services related field or equivalent experience and Registered Nursing degree Must have Registered Nursing degree.

* Two (2) years full-time equivalent of direct clinical care to the consumer.

* Related business, case management and utilization management experience preferred.

* Spanish speaking ability preferred

* Excellent oral and written communication, listening, interpersonal, customer service and telephone skills.

* Intermediate proficiency in the use and knowledge of MS Office software.

* Demonstrated ability to understand and adhere to statutes, regulations and company policies and practices.

* Demonstrated skill in working independently with minimal direction, multi-tasking skills, determine the relative importance of each, adhere to deadlines, and complete assignments accordingly.

* Good analytical, problem solving and decision-making skills and be able to deal with people in difficult situations.

* An equivalent combination of education and experience may be substituted for the requirements listed above.


* Board of Nursing Registered Nurse (RN) licenses, certifications and designations for applicable states. Must obtain and maintain RN license(s), certifications and designations for any state requested to meet existing and new business growth and needs. This includes all states and areas in which EMPLOYERS conducts business, and will not be limited to basic compact state licensure.

* Certified Case Manager (CCM).

As a dynamic, fast-growing provider of workers' compensation insurance and services, we are seeking a goal-oriented individual willing to put their ideas to work!

We offer a positive, challenging work environment, combined with an opportunity to build your career as you help us grow our business, in innovative and imaginative ways that are uniquely EMPLOYERS®!

Headquartered in Reno, Nevada, EMPLOYERS attributes its long-standing success to its most valuable resource, our employees across the United States. EMPLOYERS is known for the quality service and expertise we provide to our clients, and the exemplary work environment we provide for our employees.

We live and breathe our core values: Integrity, Customer Focus, Collaboration, Initiative, Accountability, Innovation, and Personal Fulfillment. These are the pillars that support how we do business with our clients as well as how we treat each other!

At EMPLOYERS, you'll discover an energetic environment that inspires top achievement. As "America's small business insurance specialist", we have the resources, a solid reputation and an expanding nationwide identity to enrich your work/life and enhance your career.