Registered Nurse Case Manager    
San Francisco, California     
Description:
Summary
Duties and Responsibilities
1.       Provides proactive care management services and has responsibility for cases assigned; Provides specialized medical expertise on complex claims to assist Examiner with reserve estimates as needed; Attends field medical appointments and program staffing when indicated and driving to facilities, Injured Employee’s homes, and hospitals; Notifies Examiner of any status change.
2.       Assigns tasks to the Care Management Technician.
3.       Determines if recommendations for medical care compares with the company approved best practice standards as well as utilization of nationally recognized guidelines such as ACOEM, Milliman, and Medical Disability Advisor.
4.       Understands URAC standards as they apply to utilization management and applies this understanding in the case/care management process.
5.       Authorizes services based on company Medical Policy and approved best practice standards including selection of appropriate medical provider from contract provider network for referrals, medical treatment, 2nd opinions, expert medical opinions etc., as well as appropriate utilization of sole source providers and referral to Medical Directors/Advisors for non-certification/dispute resolution.
6.       Proactively applies case management assessment, planning, implementation, coordination and evaluation (APICME) processes to all assigned care managed cases.
7.       Utilizes appropriate designated panel providers as per provider contracts.
8.       Communicates and documents medical care management needs/rationale based upon company approved best practice standards to Clients, Providers, and Insurer.
9.       Implements proactive interventions to achieve client goals and objectives in collaboration with Provider, Employer, Examiner, and Injured Employee. Documents all specific case activities i.e. all aspects of care management efforts, discussions and variances with Injured Employees, Employers, Providers, Examiners, etc. in Focus claims system.
10.   Develops and implements the proactive case management plan based on the medical treatment plan per the treating physician, in conjunction with company approved Medical Policy and best practice standards, length of disability (LOD), temporary and permanent limitations, permanent total disability (PTD) requests, obtaining job description and discharge plan assessment(s) utilizing company approved best practice standards/guidelines as per ACOEM, Milliman, and Medical Disability Advisor.
11.   Confers with or refers cases to Medical Directors/Advisors for review when indicated.
12.   Orchestrates and supports early return to work initiatives by assisting Examiner, Injured Employee and Provider.  Coordinates with Providers to expedite return to work (RTW).
13.   Facilitates collaborative joint action plans, to include medical aspect/plan with Examiner.
14.   Directs Injured Employee to other resources for non-industrial issues.
15.   Evaluates Injured Employee compliance with care plan and ERTW.
16.   Provides triage services on cases as designated.
17.   Assists in contested case preparation/documentation and testimony when requested on company managed claims.
18.   Maintains nursing license and certifications as applicable by completing continuing education units as required by respective State Boards of Nursing and/or credentialing organization as applicable, and practices within their scope of licensure and certification.
19.   Adheres to all state laws and regulations that apply.
20.   Respects and observes Injured Employee’s right to confidentiality at all times.
21.   Maintains confidentiality of all data and records.
22.   Other duties as assigned or as situation dictates.
WORKING CONDITIONS
·        Some travel is required either to other office locations or to outsides offices/homes, generally up to 25% of the time.
·        Compressed Work Week (4/10)
Minimum Qualifications
· Nursing degree and current Board of Nursing Registered Nurse licenses for applicable states as
indicated.  Must maintain license while employed in this position.
· Must have a minimum of 3 years acute nursing practice and/or experience, or an equivalent
combination of education and work experience.
· Knowledge of MS Office
Preferred but Not REQUIRED
· Certification in case management, occupational health nursing, rehabilitation RN, life care planning,
etc. is preferred.
· Related business, case management and utilization management experience is preferred.
The incumbent, under the direction of the Supervisor of Care Management Services or the direction of the Director of Care Management, will:  provide proactive care management services promoting patient restoration of health and reduction of disability; and maintain a caseload of serious to complex cases for care management in applicable states as indicated.
  Compensation: $85,000.00 - $88,000.00 Annually
  Benefits: As a dynamic, fast-growing provider of workers' compensation insurance, and service we are seeking creative, goal-oriented individuals willing to put their ideas to work. We offer a positive, challenging work environment and an opportunity to grow your career as you help us grow our business.
In addition to a competitive salary, eligible employees can participate in a benefits program which includes the following features:
    * Group health coverage
    * Dental and vision coverage
    * Basic Life and AD&D insurance
    * Employee Assistance Program
    * Vacation time accrual
    * 401K retirement plan
    * Opportunities for advancement
If you are ready to join a successful team we want to hear from you.