Telephonic Nurse Case Manager - California RN Required

About the position Responsibilities • Uses clinical/nursing skills to determine whether all aspects of a patient’s care, at every level, are medically necessary and appropriately delivered. • Perform Utilization Review activities prospectively, concurrently or retrospectively in accordance with the appropriate jurisdictional guidelines. • Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary • Responsible for accurate comprehensive documentation of case management activities in case management system. • Uses clinical/nursing skills to help coordinate the individual’s treatment program while maximizing quality and cost-effectiveness of care including direction of care to preferred provider networks where applicable. • Addresses need for job description and appropriately discusses with employer, injured employee and/or provider. Works with employers on modifications to job duties based on medical limitations and the employee’s functional assessment. • Responsible for helping to ensure injured employees receive appropriate level and intensity of care through use of medical and disability duration guidelines, directly related to the compensable injury and/or assist adjusters in managing medical treatment to drive resolution. • Communicates effectively with claims adjuster, client, vendor, supervisor and other parties as needed to coordinate appropriate medical care and return to work. • Performs clinical assessment via information in medical/pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place • 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. • Partners with the adjuster to develop medical resolution strategies to achieve maximal medical improvement or the appropriate outcome • Evaluate and update treatment and return to work plans within established protocols throughout the life of the claim. • Engage specialty resources as needed to achieve optimal resolution (behavioral health program, physician advisor, peer reviews, medical director). • Partner with adjuster to provide input on medical treatment and recovery time to assist in evaluating appropriate claim reserves • Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards. • May assist in training/orientation of new staff as requested • Other duties may be assigned. • Supports the organization's quality program(s). Requirements • Active unrestricted RN license in California is required. Arizona is preferred • Five (5) years of related experience or equivalent combination of education and experience required to include two (2) years of direct clinical care OR two (2) years of case management/utilization management required. • Knowledge of workers' compensation laws and regulations • Knowledge of case management practice • Knowledge of the nature and extent of injuries, periods of disability, and treatment needed • Knowledge of URAC standards, ODG, Utilization review, state workers compensation guidelines • Knowledge of pharmaceuticals to treat pain, pain management process, drug rehabilitation • Knowledge of behavioral health • Excellent oral and written communication, including presentation skills • PC literate, including Microsoft Office products • Leadership/management/motivational skills • Analytic and interpretive skills • Strong organizational skills • Excellent interpersonal and negotiation skills • Ability to work in a team environment • Ability to meet or exceed Performance Competencies • Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines • Computer keyboarding • Hearing, vision and talking Nice-to-haves • Bachelor's degree in nursing (BSN) from accredited college or university or equivalent work experience preferred. • Certification in case management, pharmacy, rehabilitation nursing or a related specialty is highly preferred. • Ability to acquire, and maintain, appropriate Professional Certifications and Licenses to comply with respective state laws may be required • Preferred for license(s) to be obtained within three - six months of starting the job. • Written and verbal fluency in Spanish and English preferred Benefits • Medical & Dental Plans • Life Insurance, including eligible spouses & children • Health Care Flexible Spending • Dependent Care • 401k Savings Plans • Paid Time Off