Telephonic Nurse Case Manager

Rising Medical Solutions Riverside , CA 92505

Posted 4 days ago

Are you an RN with CA License? Do you have case management or utilization review experience? If so, look no further than Rising Medical Solutions. Our Telephonic Nurse Case Management (TCM) Team is growing and you may be our perfect match! This position will be based onsite at one our client's offices located in: Riverside, Rancho Cordova, San Jose, or Torrance, CA.

What exactly does a TCM do?

  • Applies established protocols, criteria, guidelines, references and resources to determine medical appropriateness of services provided to injured workers in a cost-effective manner. Assesses medical needs via evaluation and assessment of subjective, objective symptoms and complaints, evaluation of the injured workers functional abilities in order to formulate and deliver a plan with specific goals and objectives. Case Management plans should primarily focus on actions which facilitate return to work without compromising the recovery or medical treatment of the injured worker. Gathering of information and the coordination of multiple medical services are achieved via interface with the providers of care, the patient, and the injured workers support system. Ongoing monitoring and gathering of information from clients, patients and the providers of care are necessary to validate current plan of care or changes in order to accommodate the injured workers recovery pattern.
  • Delivery of appropriate and timely medical services is implemented via vigilant Case Management follow-up and through put efforts. Monitoring of expedient services will assure a continuation of exemplary Keenan customer service and will avoid a delay in the timely return to work of the patient.
  • Expertise is required in assessing rehabilitative needs and service coordination. Appropriate recovery is measured via referencing and documentation of the REED Group Disability Guidelines (MDA), ACOEM, MTUS, and Anthem Workers Compensation Supplemental Care Protocols. Assessment of rehabilitative progress is monitored by frequent conference with the providers of care. Coordination of Home Care Services, Durable Medical Equipment, Pharmaceutical Services, and other auxiliary rehab/medical services is monitored for continued efficacy.
  • Communicates with medical providers and the employer to return injured employee to work, either modified or full duty. A focus on nurturing a healthy recovery processes is emphasized.
  • Refers medical services which are not in alignment with nationally recognized guidelines to the appropriate physician advisor partners for review and decision making.
  • Creation and oversight of appropriate correspondence in relation to the case management and utilization review process.
  • Assessment of the injured workers psychosocial status is achieved via frequent contact and relationship building. Barriers to recovery and progression are diverted via frequent conference and collaboration with the injured worker as well as the injured workers support system. Particular attention is paid to the RecoveryWellness vs. VictimIllness Injured Worker Recovery Model.
  • Documents decisions, rationale, and resources regarding cases by maintaining on-line input into case management systems and another applications designated to be applicable to the nurses workflow.
  • The Nurse Case Manager must have the ability to review data as it relates to treatment and the costs of care and must identify trends to the appropriate parties
  • Special assignments/projects as designated by the Nurse Manager. May include evaluation of work audit outcomes or Reserves Analysis.
  • Collaborative team play is a requirement: Ability to work cooperatively with internal and external clients is a must. Must have excellent customer service skills and the nurses behavior should reflect a businesslike tone and affect.
  • It is an essential function of this job that you arrive at your designated office location on-time, and ready to work your scheduled hours.
  • Other duties may be assigned.


  • Associate or Bachelor's degree in nursing or a related field preferred
  • RN with active license in California required
  • Any other licenses or certifications is beneficial
  • 3-5 years of clinical practice or 2 years of workers compensation case management or UR experience preferred
  • Experience with short-term or long-term disability, or liability claims a plus
  • Medical/healthcare/Workers Compensation claims/bill review experience a plus
  • Well-developed time-management, organization, and prioritization skills
  • Excellent analytical skills
  • Excellent oral and written communication
  • Ability to gather data, compile information, and prepare summary reports
  • Strong interpersonal and conflict resolution skills
  • Experience in a fast-paced, multi-faceted environment
  • Demonstrated persistence and attention-to-detail
  • Knowledge of medical billing procedures. Understanding of CPT and ICD-9 codes and Medicare guidelines
  • Working knowledge of: Microsoft Office products, including: Word, Excel, and Outlook; Skype for Business
  • Ability to stay calm during stressful situations
  • Customer-service orientation


  • Compensation commensurate with skills and experience.
  • Competitive benefits package.
  • Employment within a firm committed to core values, staff development, emerging technology, private ownership, and controlled growth/reinvestment in the future.
  • Opportunity to make a difference in reducing health care costs and increasing the value of health care to individuals and their employers.
  • Daily interaction with some of the most talented people in the medical cost-containment industry.
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Telephonic Nurse Case Manager

Rising Medical Solutions