Location Requirement
Candidates must be based in the South Bay region of Los Angeles County, CA, including Gardena, Long Beach, and nearby communities, and be willing to travel locally for field case management visits.
Your Impact
You'll provide effective case management services in a cost‑effective manner, delivering medical case management consistent with URAC standards, CMSA Standards of Practice, and Broadspire QA Guidelines. You'll support patients/employees receiving benefits under insurance lines including Workers' Compensation, Group Health, Liability, Disability, and Care Management.
Responsibilities
- Reviews case records and reports, collects and analyzes data, evaluates injured worker/disabled individual's medical status, identifies needs and obstacles to medical case resolution and RTW by providing proactive case management services.
- Render opinions regarding case costs, treatment plan, outcome and problem areas, and makes recommendations to facilitate case management goals to include RTW.
- Demonstrates ability to meet administrative requirements, including productivity, time management and QA standards, with a minimum of supervisory intervention.
- May perform job site evaluations/summaries to facilitate case management process.
- Facilitates timely return to work date by establishing a professional working relationship with the injured worker/disabled individual, physician, and employer. Coordinate RTW with injured worker, employer and physicians.
- Maintains contact and communicates with claims adjusters to apprise them of case activity, case direction or secure authorization for services. Maintains contact with all parties involved on case, necessary for case management the injured worker/disabled individual.
- May obtain records from the branch claims office.
- May review files for claims adjusters and supervisors for appropriate referral for case management services.
- May meet with employers to review active files.
- Makes referrals for Peer reviews and IME's by obtaining and delivering medical records and diagnostic films, notifying injured worker/disabled individual and conferring with physicians.
- Utilizes clinical expertise and medical resources to interpret medical records and test results and provides assessment accordingly.
- May spend approximately 70% of their work time traveling to homes, health care providers, job sites and various offices as required facilitating RTW and resolution of cases.
- Meets monthly production requirements and quality assessment (QA) requirements to ensure a quality product.
- Reviews cases with supervisor monthly to evaluate files and obtain directions.
- Upholds the Crawford and Company Code of Business Conduct at all times.
- Demonstrates excellent customer service, and respect for customers, co-workers, and management.
- Independently approaches problem solving by appropriate use of research and resources.
- May perform other related duties as assigned.
Qualifications
- Associate's degree or relevant course work/certification in Nursing is required; BSN Degree is preferred.
- Minimum of 1-3 years diverse clinical experience and one of the below:
- Certification as a case manager from the URAC-approved list of certifications (preferred);
- A registered nurse (RN) license.
- Must be compliant with state requirements regarding national certifications.
- General working knowledge of case management practices and ability to quickly learn and apply workers compensation/case management products and services.
- Excellent oral and written communications skills to effectively facilitate return-to-work solutions within a matrix organization and ensure timely, quality documentation.
- Excellent analytical and customer service skills to facilitate the resolution of case management problems.
- Basic computer skills including working knowledge of Microsoft Office products and Lotus Notes.
- Demonstrated ability to establish collaborative working relationships with claims adjusters, employers, patients, attorneys and all levels of employees.
- Demonstrated ability to gather and analyze data and establish plans to improve trends, processes, and outcomes.
- Excellent organizational skills as evidenced by proven ability to handle multiple tasks simultaneously.
- Demonstrated leadership ability with a basic understanding of supervisory and management principles.
- Active RN home state licensure in good standing without restrictions with the State Board of Nursing.
- Must meet specific requirements to provide medical case management services.
- Minimum of 1 National Certification (CCM, CDMS, CRRN, and COHN) is preferred. If not attained, must plan to take certification exam within proceeding 36 months.
- National certification must be obtained in order to reach Senior Medical Case Management status.
- Travel may entail approximately 70% of work time.
- Must maintain a valid driver's license in state of residence.