TPA Medical Case Manager

General Description: Manage medical activities of workers compensation and disability claims for Third Party Administration (TPA) accounts. Coordinate with patients, physicians, other health care providers and employers. Facilitate positive patient outcomes, timely return to work, and efficient claims resolution.

Responsibilities:

• Manage activities of workers compensation and disability claims, case management, and utilization review. Ensure compliance with established policies and procedures and applicable legal and regulatory guidelines.
• Manage ongoing managed care activities. Includes case management of medical aspects of workers compensation and disability claims for TPA accounts.
• Coordinate with patients, physicians, health care providers, and employers to facilitate positive patient outcomes, timely return to work, and efficient claims resolution and utilization review.
• Gather demographic and clinical information on inpatient admissions and outpatient treatment.
• Certify the medical necessity of services. Assign appropriate length of stay and treatment plans.
• Present case management and utilization review information to prospects and clients.
• Assist adjuster with complex medical aspects as necessary. Resolve escalated issues and problems by conferring with staff, management, other internal departments, outside contacts, and clients.
• Perform case management and other activities as workload requires. Respond to requests from insurance carriers, medical personnel, attorneys, etc.
• Assess internal and external customer needs. Manage activities to ensure services are delivered efficiently.
• Evaluate and update treatment and return to work plans within established protocols.
• Communicate with internal teams and management on account information and status updates.
• Maintain knowledge of current developments in the managed care industry. Includes regulatory issues and guidelines changes.

Knowledge, Skills and Abilities:

• Registered Nurse (RN) from accredited college. Must have an active state license and eligible to obtain additional state licenses.
• 5 to 10 years workers' compensation and disability case management experience required.
• Masters degree in business, healthcare or other related field preferred.
• CCM, CRS or CDMS certification required.
• Excellent understanding of managed care industry practices. Includes medical case management, utilization review, and related legal and regulatory guidelines.
• Strong clinical background in orthopedics, neurology or rehabilitation.
• Highly organized, with ability to manage work involving large client volume.
• Strong understanding of managed care technology applications.
• Excellent verbal and written communication skills.
• Ability to work well in a team environment.
• Must have strong analytical thinking and problem-solving skills.

Physical Demands:

Work is performed in a climate controlled office environment with minimal noise and limited to no exposure to chemicals or toxins. Employees operate office equipment including telephone - headset, computer, computer monitors, keyboard, mouse, copier, scanner, and mail machine. Physical tasks of job include walking, sitting, standing, and bending.

Analysis of Physical Demands:

• Constantly (over 66% of time) work performed requires employees to use repetitive hand motions such as typing, using a keyboard, and sitting at a desk.
• Frequently (34%-66% of time) work performed requires employees to handle and grasp things, walk on normal surfaces, stand, and bend.
• Occasionally (1%-33% of time) work performed requires employees to drive to client appointments, have repetitive foot movements, walk on uneven or slippery surfaces to and from work and occasionally reach outward to grab things and bend.
• Rarely (< than 1 hour per week) work performed requires lifting/carrying items that range from 10-50lbs, pushing/pulling items that range from 10-50lbs, twisting/turning including reaching over shoulder or above head, kneeling or squatting.

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