Medical Management Specialist (Position Closes 6/12/2019 At 11:59Pm) (60012)

Montana State Fund Helena , MT 59624

Posted 2 months ago

At Montana State Fund, serving the businesses of Montana is what we do and it's who we are. It's what makes us different. We partner with employers and their employees to care for those injured on the job and we champion a culture of workplace safety for our fellow Montanans.

On the Medical Services Team, we're providing a high level of medical expertise across the organization to support both internal and external customers. This is an excellent opportunity for a medical professional with clinical experience to provide valuable input and guidance while working in a collaborative environment with a team of passionate, motivated professionals. If you want to make a difference working on rewarding and dynamic challenges read on to learn more about this exciting opportunity to join the Montana State Fund team!

About the Role

With a high level of medical expertise and under minimal supervision serves as medical case management expert, auditor and resource to Montana State Fund regarding medical claim management and Claims Best Practices and provides recommendations for longer term claims that may have complex medical issues to assist in determining appropriate medical reserves. At times of decreased staffing, will provide early intervention medical case management to examiners and injured workers.

What You'll Do

  • Provide medical case management to claim examiners and IE's relating to diagnosis, treatment plans, related expenses, medical services, and offer suggestions for bringing the claim into alignment, for short and long range action strategies to move the claim to medical stability, settlement, or closure. Research and analyze provider treatment plans with evidence-based best practices and serve as a resource relating to the injured worker diagnosis treatment plan and medical services. Analyze medical claims management issues and assist with negotiation of appropriate treatment plans with medical providers when necessary. (30%)
  • Performs and analyzes Quality Assurance (QA) Reviews for Medical Case Managers (MCM) on a quarterly basis. Creates a quarterly report for the Nurse Manager outlining QA results. Identifies trends and suggests changes in processes, procedures and or guidelines and makes recommendations for implementing changes that would be beneficial to the nursing staff. (30%)
  • In collaboration with the Strategic team, identify claims that will benefit from intensive file reviews, assist Strategic team with implementing long range action plan strategies that assist with management of claims, including medical stability and review for rated age and large loss. (25%)
  • Assist with new hire orientation to claims staff regarding medical management team member's responsibilities. Provides orientation to the medical case manager regarding the nurse's roles and responsibilities and completes other duties as assigned. (15%)

Required Skills

Key Activities

  • Provide medical case management services on a limited basis to a limited number of claims examiners to support medical case management team with overflow.

  • Communicates with injured workers, medical providers and others.

  • Assists Claims Examiners with injured worker diagnoses, treatment plans or medical services.

  • Provide education, consultation, and assist with RTW efforts.

  • Reviews Large Loss claims and completes rated ages from the Strategic Team, collaborates with the Claims Examiner after the review, and attends the scheduled Large Loss meeting.

  • Attend, large loss meetings to support recommendations in determining the final plan of action for the claim being reviewed and as needed will attend litigation, mediation, DOM care or large purchase meetings.

  • Research, analyze and provide treatment plans with evidence-based best practices, and Montana Utilization and Treatment Guidelines in collaboration with other medical professionals to ensure the best possible medical outcome for the injured employee.

  • Analyze medical claims management issues with other claims professionals through communication, coordination and facilitation of information to assist with return to work efforts.

  • The MMS may be required to make presentations to claims examiners, other nurses or at All Employee meetings.

  • Assist MCM and CE with file reviews during times of MCM shortage or high volume of EI claims, for early intervention of claims focusing on medical provider records. Interviews the injured employee and collaborates with other team members to facilitate and identify appropriate medical care.

  • Assists with and, conducts quality assurance reviews for medical case managers and strategic claim management on a quarterly basisand reports results to Nurse Manager.

  • Analyzes quality assurance reviews for medical case and strategic claim management on a quarterly basis and reports results to Nurse Manager; identifies trends and proposes actions steps for improvements.

  • Assists with orientation of new hires to Medical Management processes and MT Utilization and Treatment guidelines and ongoing training as needed.

  • Provides reports and trends as directed.

Required Experience

What You'll Need (Minimum Qualifications)

Required

  • Current RN licensure (BSN preferred) with six (6) years clinical experience.

Preferred

  • Case management experience in workers' compensation.

  • Any of the following certifications:

  • Certified Case Manager, Certified Rehabilitation Registered Nurse, Certified Occupational Health Nurse, Certification in Case Management, Community Health, Certified Managed Care Nurse, Home Health or Medical-Surgical Nursing.

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Medical Management Specialist (Position Closes 6/12/2019 At 11:59Pm) (60012)

Montana State Fund