Job description

UPMCs Health Plan is hiring a Clinical Case Manager to support the Workers' Compensation Claims Admin team. This is a remote position but may require travel into the downtown Pittsburgh office for meetings and trainings as needed.

Workpartners administers both occupational and non-occupational disability management programs for UPMC and external clients. Work Partners' Nurse Case Managers are responsible for assisting the claims staff and clients in the medical and disability case management of all assigned cases.

Responsibilities:

In special circumstances, attend physician appointments when needed to enhance communication regarding treatment plan, physical capabilities, etc.
Provide medical resource for the claims staff and function as part of the medical escalation process as per Nurse Case Manager criteria. o Interact with the Medical Director as per escalation process.
Assist as needed with coordinating appointments with panel provider or other providers. Ensure that the provider has the required documentation, medical reports, diagnostic test results, and/or job description, prior to the scheduled examination. o Proactively communicate via phone or fax to the treating physician prior to scheduled appointments any pertinent information that may impact the treatment plan
SPECIFIC RESPONSIBILITIES: Utilizing the essential case management activities of assessment, planning, implementation, coordination, monitoring, evaluation, outcomes, and general the case manager activities shall primarily include, but are not limited to the following: Participate as part of a multidisciplinary team in the management of specific account program assigned.
Provide `Best in Class' Nurse Case Management on all claims assigned. These claims may include 1) all lost time claims; 2) all restricted medical-only claims remaining open after 30 days; 3) any other complicated claim assigned by the supervisor; 4) all referrals from external client(s).
Utilize standardized duration resources to guide return-to-work timelines and communicate with treating physicians in seeking clarification if injured employees fall outside anticipated durations.
GENERAL RESPONSIBILITIES:In conjunction with the claims adjusters and treating medical personnel, the NCM will monitor each claim with the objective of assisting an employee in receiving any needed medical care as a result of their injury/illness, identifying physical capabilities that allow the employee to return to work as soon as is medically possible following standardized disability guidelines, identifying any known barriers that would prevent successful return to work, and collaborate in conjunction with treating provider(s) and claims staff to develop strategies to bring each claim to an anticipated successful close. In order to meet this objective, the NCM must be familiar with the worlds of occupational and non-occupational medicine; and with the medical details of each injury/illness, including the current treatment and the anticipated return to work date.
Keep claims adjusters or non-occupational client apprised of an employee's progress and medical status (maintaining HIPAA privacy standards for client interaction). Document all information in a timely manner in the claims system and maintain diary system.
Review medical information and provide feedback to claims staff with regards to the causal relationship of the work injury to the medical evidence provided.
Actively monitor employees' care and progress during an injury or illness and interact with appropriate panel provider/treating physician to assure understanding of the treatment plan
Prepare in whole or in part (along with the claims adjusters) letters to physicians, letters regarding Independent Medical Evaluations, or other documentation requiring a medical perspective
Review reports: weekly, monthly and quarterly to evaluate the effectiveness of the medical delivery system, and to identify trends and cost containment opportunities.
Target specific high-cost drivers and develop strategies to minimize the impact of such on the overall cost of the program
Registered Nurse with current Pennsylvania licensure. Additional licensure in NJ or DE is a bonus.
Minimum 5 years clinical experience and a strong medical background.
BSN preferred or equivalent professional and educational experience required.
Expertise in workers compensation, disability management, risk management, insurance, safety and/or case management experience is strongly preferred.
Previous occupational medicine experience preferred.
Knowledge of DOT regulations, FML, ADA, Short Term/Long Term Disability management preferred
Excellent organizational and communication skills required.
Certification in Case Management strongly encouraged

Licensure, Certifications, and Clearances:

Registered Nurse (RN)
Act 34
Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran

Annual

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