Job Description
Effectively triages claims.
On selected cases:
Prioritizes contacts based on severity and urgency. Completes timely and regular contacts with medical providers. Obtains and assesses current medical information and maintains in file. Effectively negotiates treatment plan and work status with medical provider. Authorizes payment for treatment in compliance with Labor Code statutes and company standards. Facilitates the earliest appropriate return to work release and coordinates RTW efforts with team members. Diaries file appropriately and follows up on requested/negotiated treatment plans. Facilitates Maximum Medical Improvement and discharge from care. Consistently and accurately documents interventions and rationale for decisions in the appropriate system screen. Utilizes and manages resources appropriately, including External Case Managers and UR vendor(s). Develops and maintains relationships and partnerships with local medical providers via telephone.
Medical Case Management Responsibilities:
Directs treatment to appropriate panel and network physicians, PTP or specialist, and hospitals. Reviews selected files timely and makes appropriate recommendations, documenting all actions and rationale for decisions in the appropriate system screen. Judges necessity for on-site medical case management, with focus on catastrophic intervention.
Training Responsibilities:
Understands and utilizes MMP reports to assess and improve results and quality. Trains other disciplines to utilize this information appropriately. Educates claim staff in ongoing UR and RTW processes. Assists with development of a consistent approach to eliminate overutilization of medical services. Assists and trains team members on selection of appropriate medical providers. Educates examiners, employers and other Zenith staff on medical issues within corporate guidelines. Assists with training and mentoring LVN staff and peers.
Professional Development:
Maintains clear and active RN license in state(s) employed. Pursues continuing education to maintain RN active status, in technical areas related to Workers' Compensation injuries/illnesses. Pursues continuing education relating to current Utilization Review practices. Possesses or pursues additional professional designations such as CIRS, CCM, CRRN. Pursues self-development related to being an effective trainer. Continually updates knowledge of Workers' Compensation statutes and changes through self-development program including researching, reading, and attending classes or seminars. Maintains strong written and verbal communication skills. Requirments:
Active and clear RN License. Valid Driver's License in good standing. 3 years experience in utilization review / medical case management (or equivalent prior experience), preferably in workers' compensation area. 3 to 5 years clinical practice with experience in orthopedics, neurology, or occupational medicine preferred. Excellent interpersonal and communication skills - oral and written. Familiarity with personal computers preferred. Bi-lingual Spanish preferred.
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