TCM/FCM Hybrid Nurse Case Manager

As our Nurse Case Manager, you will coordinate care for injured or disabled individuals, including high-risk, high-cost, and complex cases. The role applies professional nursing judgment and case management principles to assess needs, facilitate appropriate treatment, monitor progress, support functional recovery and return-to-work goals, and promote quality, cost-effective outcomes through collaboration with clients, patients, employers, providers, attorneys, and other stakeholders.

In this job, you will:

• Maintain a mix caseload of field and/or telephonic case management files. Typical caseload of 30-40 cases.

• Establish collaborative relationships and serve as an intermediary among clients, injured or disabled individuals, employers, providers, attorneys, and other involved parties.

• Manage a caseload of high-risk, high-cost, and complex cases by assessing clinical, functional, psychosocial, and vocational needs.

• Assess, coordinate, implement, monitor, and evaluate individualized care plans using principles of medical necessity, appropriateness of care, case management, and managed care.

• Promote quality, cost-effective care across the health care continuum to support optimal function and safe, timely return to work when appropriate.

• Assess injury severity, extent of disability, treatment plans, functional abilities, and physical job requirements to develop return-to-work strategies and help manage future medical exposure.

• Track and report case management activity and maintain organized, timely, and accurate clinical documentation of interactions, interventions, barriers, outcomes, and communications.

• Respond to written and telephonic inquiries regarding case status and document relevant case information in Rising systems and client claims systems, when applicable.

• Adhere to applicable state, national, accreditation, departmental, and client-specific quality standards, guidelines, policies, procedures, and reporting requirements.

• Escalate potential clinical, operational, service, or compliance concerns to the appropriate supervisor as they become evident.

• Assist with URAC accreditation activities and the maintenance of related policies and procedures.

• Provide professional nursing insight to Rising Medical Bill Analysis and other internal teams, as requested.

Requirements

• Current, active, unrestricted RN license in primary residence state and preferably in a compact state

• California RN license a plus

• Full Time – 9:00am CST to 5:30pm CST, with the ability to flex time based on the jurisdiction

• Strong computer skills required – Microsoft Suite (Outlook, Excel, Word, etc.)

• 3-5 years of case management experience with 1-2 years of specific worker’s compensation NCM experience

• Experience with Workers’ Compensation, liability, or disability claims

• Medical bill review experience with Workers’ Compensation, Auto, or Health Insurance carriers is preferred

• The ability to maintain confidentiality of all information, policies, and procedures

• The ability to set priorities and work both autonomously and as part of a team

• Demonstrated sensitivity to culturally diverse people and situations

• Well-developed time management, organization, and prioritization skills

• Knowledge of utilization management, case management, and healthcare provided throughout the health continuum

• Excellent oral and written communication skills with a heavy focus on customer-service

• The 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

• The ability to stay calm during stressful situations

• Having your CCM, and/or any other insurance/workers’ compensation certifications is a huge plus!

• Professional Nursing degree (ASN, BSN)

Benefits

• Competitive base salary, profit sharing, 401k matching, generous time off, and career growth opportunities

• A relaxed, yet upbeat, work environment

• Rising was named a Top Workplace in the healthcare industry for 2023! Check out our profile here: Rising Medical Solutions, Inc Profile (topworkplaces.com) (https://topworkplaces.com/company/rising-medical-solutions/)

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If you are ready to join a team of professionals dedicated to making a difference and making lives better, please apply today!