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Provision of comprehensive Utilization Management, incorporating the strategies of cost containment, appropriate utilization of services, and Case Management in a cooperative effort with other parties which helps address the issues of access to quality healthcare services at an affordable cost. Responsible for the performance of Utilization Review services, including pre-admission certification, second surgical opinion, concurrent utilization review, DRG validation, as well as assessment, planning, coordination, implementation and evaluation of injured/disabled individuals involved in the medical case management process. Works as an intermediary between carriers, attorneys, medical care providers, employers and employees to ensure appropriate and cost-effective healthcare services and a medically rehabilitated individual who is ready to return to an optimal level of work and functioning.

Main responsibilities include but are not limited to:

Uses clinical/nursing skills to determine whether all aspects of a patient's care, at every level, are medically necessary and appropriately delivered.

Interface with external agencies/representatives relative to the utilization review process including, but not limited to, Third-Party Payers, Insurance Companies and Providers.

Perform Utilization Review activities prospectively, concurrently or retrospectively with complete and timely reports to clients and providers.

Screens provided medical information and medical records for medical necessity and appropriateness, comparing information to current medical criteria.

Refers for Physician Review those cases not meeting our medical criteria.

Responsible for accurate completion of case data in the Managed Care System, as well as the accurate and timely generation of required correspondence/review notification.

Report to Branch Manager/Supervisor potential problems identified during reviews or data collection (i.e. questions regarding medical criteria).

Complete the Issues for Quality Improvement Form when indicated by our Policy & Procedure Manual.

Maintain daily records of all contacts, telephone calls.

Attend scheduled staff meetings and in-service education programs.

Uses clinical/nursing skills to help coordinate the individual's treatment program while maximizing quality and cost-effectiveness of care. Performance is monitored daily by Supervisors and/or Branch Manager.

Initial review and assessment of case information and referral objectives.

Verify employee's job Title/Description. Do we have job analysis? If not, is it available?

Perform three-point contact to include the following: Contact Employee, Contact Provider, Contact Employer/Adjuster/Insurer:

Objectively and critically assesses all information related to the current treatment plan to identify barriers, clarify or determine realistic goals and objectives, and seek potential alternatives.

Maintain daily records of all contacts.

Generate and fax, if requested, Initial or 72-hour report, including appropriateness of treatment plan and Case Management recommendations.

Serves as an intermediary to interpret and educate the individual on his/her disability, and the treatment plan established by the case manager, physicians, and therapists. Explains physician's and therapists' instructions, and answers any other questions the claimant may have to facilitate his/her return to work.

Works with the physicians and therapists to set up medical assessments to develop an overall treatment plan that ensures cost containment while meeting state and other regulator's guidelines.

Researches alternative treatment programs such as pain clinics, home health care, and work hardening. Coordinates all aspects of the individual's enrollment into the programs, and then monitors his/her progress, to ensure quality and cost-effectiveness of care and minimize time away from work.

Works with employers on modifications to job duties based on medical limitations and the employee's functional assessment. Helps employer rewrite a job description, when necessary and possible, to return the client to the workplace.

Monitors/evaluates the employee's progress.

Supply employer/adjuster/insurer with periodic reports agreed to in original contract, but not less than biweekly.

Provides input on the performance of support staff to their supervisor.

Track client updates by use of daily open listing.

Maintaining the necessary credentials and demonstrating a level of professionalism within the work place and in dealing with injured workers reflects positively on the company.

May assist in training/orientation of new staff as requested.

Monitors functions assigned to non-case managers and provides input on the performance of support staff to their supervisor.

Other duties may be assigned.

EDUCATION: Diploma, Associate or Bachelors Degree in Nursing required. Advanced Degree preferred.

EXPERIENCE: Minimum of two (2) years full time equivalent of direct clinical care to consumers/ clinical practice. Workers' compensation-related experience preferred.

MINIMUM QUALIFICATIONS: A current, unrestricted license or certification to practice a health or human services discipline in a state or territory of the United States that allows the health professional to independently conduct an assessment as permitted within the scope of practice of the discipline; or

In the case of an individual in a state that does not require licensure or certification, the individual must have a baccalaureate or graduate degree in social work, or another health or human services field that promotes the physical, psychosocial, and/or vocational well-being of the persons being served, that requires:

A degree from an institution that is fully accredited by a nationally recognized educational accreditation organization;

The individual must have completed a supervised field experience, in case management, health, or behavioral health as part of the degree requirements; and

URAC-recognized certification in case management within four (4) years of hire as a case manager

CERTIFICATES, LICENSES, REGISTRATIONS: See minimum Qualifications above. Pursue URAC-recognized certification in case management (CCM, CDMS, CRC, CRRN or COHN) upon eligibility. Other state licenses/certifications as required by law. Must be a RN.

OTHER QUALIFICATIONS: Prior Utilization Review/Case Management experience preferred. Excellent interpersonal skills and phone manners. Excellent organizational skills. Ability to set priorities. Ability to work independently and as a team member. Computer literacy required.