Manager, Medical Case Management

Responsibilities

• Supervise, support, monitor and evaluate the performance of the telephonic case management (TCM) and field case management (FCM) teams to ensure the team meets performance and quality standards.
• Assist the director of managed care, claims services.
• Develop, implement, and oversee the internal TCM and FCM programs to facilitate the injured worker's recovery through coordination of medical services, return to work options and to control medical, disability and litigation costs.
• Identify issues related to delayed recovery, identify opportunities to expedite care for cost containment, use creative thinking to problem solve and provide recommendations for alternative clinical resources to support timely recovery and return-to-work.
• Provide leadership, training, coaching, claim-referral triage, and case/task assignments to the nurse case managers.
• Coordinate case management referrals to outside vendors, review performance, and assess cost containment outcomes to make amendments, as needed.
• Ensure program-level metrics are maintained and shared with stakeholders, including claims adjusting and catastrophic-claim reviews.
• Ensure internal staffing, service model, and vendor partnerships are positioned to deliver quality and scalable service in alignment with company growth.
• Coordinate nursing and other professional in-house education.
• Serve as a medical resource for internal contacts.
• Maintain strong professional working relationships with internal and external contacts.
• Maintain all required continuing education records and documentation.
• Serve on committees and special projects as assigned.
• Accountable for injured worker privacy and confidentiality in accordance with HIPAA regulations.
• Maintain certifications and RN licensure.

Qualifications

• Bachelor's degree in nursing or equivalent experience.
• Graduate of an accredited RN program and current Utah RN license.
• At least one national certification, CCM or CRRN, or other as approved.
• At least five years' clinical experience, nurse case management experience, and senior supervisory experience.
• At least three years of experience in ICU/critical care, rehabilitation, orthopedics, home health, community health, occupational health or related field.
• Thorough knowledge of workers' compensation claims and medical recovery process.
• Strong cost containment background, such as utilization review or managed care.
• Exceptional communication (verbal and written), negotiation, and computer-systems skills and technical aptitude.
• Demonstrated leadership, organizational, and management skills.