Nurse - Senior Medical Case Manager (Ca)

Crawford & Company San Diego , CA 92140

Posted 2 months ago

Excellence In Everything We Touch

Position Summary

This is a Work From Home position requiring local field case management travel.

Our ideal candidate must reside in the San Diego, CA region.

To provide quality case management services in an appropriate, cost effective manner. Provides medical case management service which is consistent with URAC standards and CMSA Standards of Practice and Quality Improvement Guidelines to patients/employees who are receiving benefits under an Insurance Line including but not limited to Workers' Compensation, Group Health, Liability and Disability.

Responsibilities

  • May assist supervisor/manager in review of reports, staff development.

  • Reviews case records and reports, collects and analyzes data, evaluates client's medical and vocational status and defines needs and problems in order to provide proactive case management services.

  • Demonstrates ability to meet or surpass administrative requirements, including productivity, time management, quality assessment (QA) standards with a minimum of supervisory intervention.

  • Facilitates a timely return to work date by establishing a professional working relationship with the client, physician and employer. Coordinates return to work with patient, employer and physicians.

  • May recommend and facilitate completion of peer reviews and IME's by obtaining and delivering medical records and diagnostic films notifying patients.

  • Manages cases of various product lines of at least 3-4 areas of service (W/C, Health, STD, LTD, Auto, Liability, TPA, Catastrophic, Life Care Planning). Specifically, the case manager should be experienced in catastrophic cases plus 2-3 additional types listed above.

  • Renders opinions regarding case cost, treatment plan, outcome, and problem areas and makes recommendations to facilitate rehabilitation goals and RTW.

  • May review files for claims adjusters and supervisors.

  • May perform job site evaluations/summaries. Prepares monthly written evaluation reports denoting case activity, progress and recommendations in accordance with state regulations and company standards.

  • May obtain referrals from branch claims office or assist in fielding phone calls for management as needed.

  • Maintains contact and communicates with insurance adjusters to apprise them of case activity, case direction or receive authorization for services. Maintains contact with all parties involved on case, necessary for rehabilitation of the client.

  • May spend approximately 70% of work time traveling to homes, health care providers, job sites, and various offices as required to facilitate return to work and resolution of cases.

  • May meet with employers to review active files.

  • Reviews cases with supervisor monthly to evaluate file and obtain direction.

  • Upholds the Crawford Code of Business Conduct at all times.

  • Demonstrates excellent customer service, and respect for customers, co-workers, and management

  • Independently approaches problem resolution by appropriate use of research and resources.

  • May perform other related duties as assigned.

Requirements

  • Bachelor's degree in a health-related field is required.

  • Three years of Workers' Compensation case management with ability to independently coordinate a diverse caseload ranging in moderate to high complexity.

  • Valid RN licensure in the state(s) the incumbent works in.

  • Minimum of 1 nationally recognized Certification from the URAC list of approved certification, preferred.

  • Must be able to travel as required.

  • Bi-lingual- Spanish, preferred.

  • Individuals who conduct initial clinical review possess an active, professional license or certification:

  • To practice as a health professional in a state or territory of the U.S.; and

  • With a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review.

  • Must maintain a valid driver's license in state of residence.

  • Demonstrated ability to handle complex assignments and ability to work independently is required.

  • Effective oral and written communication skills are required.

  • Thorough understanding of jurisdictional WC statutes.

  • Advanced knowledge to exert positive influence in all areas of case management.

  • Advanced communications and interpersonal skills in order to conduct training, provide mentorship, and assist supervisor in general areas as assigned.

  • Highly skilled at promoting all managed care products and services internally and externally.

About Us

Think all TPAs are the same? Think again. With Broadspire, our leading global third-party administrator (TPA), Crawford & Company is the consultative outsourcing partner that adapts to businesses' needs and challenges at any point of the claims processing journey. We offer casualty claim and medical management services to assist large organizations in achieving their unique goals, increasing employee productivity and reducing the cost of risk through professional expertise, technology and data analytics.

As part of the One Crawford family, Broadspire brings together the best and brightest people in the industry to deliver smart, thoughtful solutions to our clients, and we are guided by our collective value system: RESTORE.

At Crawford, we:

  • Respect our culture of integrity and ethical behavior, while embracing the unique talents of the individual and encouraging an ownership mentality among everyone.

  • Are Empowered to advance the company mission and take ownership of our individual career progression.

  • Promote Sustainability through a corporate culture in which employees are good stewards of their communities.

  • Emphasize Training and an environment where employees continually seek and share knowledge and are engaged and satisfied with their work.

  • Are One Crawford, embracing a global mindset that's inclusive, agile, mission-focused, and customer-focused.

  • Give Recognition, participating in an environment where people are rewarded for jobs well done.

  • Embody an Entrepreneurial Spirit, sharing a passion to succeed, innovate, and outpace our competitors.

We believe in leading by example at work and in our communities. We hail from more than 70 countries and speak dozens of languages, reflecting the global fabric of the audience we serve. Though our reach is vast, we proudly operate as One Crawford: united in mission, vision and values. Learn more at www.crawfordandcompany.com.

In addition to a competitive salary, Crawford offers you:

  • Career advancement potential locally, nationally and internationally. Crawford & Company has more than 700 locations in 70 countries

  • On-going training opportunities through every stage of your career

  • Strong benefits package including matching 401k; health, dental, and life insurance; employee stock purchase plans; tuition reimbursement and so much more.

Crawford & Company participates in E-Verify and is an Equal Opportunity Employer. M/F/D/V Crawford & Company is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at Crawford via-email, the Internet or in any form and/or method without a valid written Statement of Work in place for this position from Crawford HR/Recruitment will be deemed the sole property of Crawford. No fee will be paid in the event the candidate is hired by Crawford as a result of the referral or through other means.


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Nurse - Senior Medical Case Manager (Ca)

Crawford & Company