Nurse Case Manager

AF Group; Philadelphia (Philadelphia County); On-site; USD 63,000 - 90,000; Full time

Job summary

AF Group seeks a Nurse Case Manager to apply medical knowledge in reviewing workers' compensation claims, evaluating treatment plans, and overseeing care to drive timely return to work. The role involves coordinating with claimants, physicians, and handlers to ensure evidence-based, policy-aligned decisions.

The ideal candidate will hold an active RN license with BSN preferred, plus at least three years of clinical care and workers' compensation experience or related fields.

Qualifications

• RN license active and unrestricted required.
• BSN degree preferred.
• Continuous learning required as defined by the company's philosophy.
• Certification or progress toward certification encouraged.

Responsibilities

• Review and approve treatment plans for workers' compensation claims to ensure medical necessity and appropriateness.
• Coordinate claimant care with providers and claim handlers to facilitate timely return to work.
• Assess medical status and determine need for inpatient vs. outpatient care.
• Document and communicate decisions and potential ramifications to claims team.
• Ensure adherence to state workers' compensation regulations and professional conduct standards.

Skills

Clinical care knowledge

Time management

Communication

Critical thinking

MS Windows

Education

Registered Nurse license

BSN preferred

Tools

Microsoft Office

Job description

SUMMARY

The Nurse Case Manager (NCM) is responsible for applying medical knowledge in reviewing workers' compensation claims to assess, evaluate, plan, implement and oversee the treatment appropriateness for occupational injuries based upon evidence based guidelines. The NCM utilizes clinical knowledge to evaluate the medical and disability needs of an injured worker against relevant policies, facilitate coordination of the patient's medical treatment and timely return to work. The NCM engages the claimant and physician(s) in providing proactive medical and disability management, working collaboratively with claim handlers in providing focused claim resolution and return to work driven outcomes. The case management process requires a focus on customer service, skills, knowledge of setting appropriate goals and measuring outcomes to effectively ensure optimal outcomes.

RESPONSIBILITIES/ TASKS

The nurse case manager must be able to demonstrate and be accountable for the standards of practice policies and procedures, quality assurance and the goals of the organization. Also, manage treatment of claimants through the workers' compensation system based on the individual's diagnosis and state workers' compensation regulations.Obtains and reviews patient clinical status and history to determine casual nature of patient's symptoms as related to reported work injuries. Applies knowledge of age-specific, cultural diversity, psycho/social and developmental issues during the interview process, documentation and intervention with the claimant, their family or significant other. Determines the medical necessity/reasonableness of proposed and ongoing treatment as well as inpatient or outpatient hospitalization for each lost-time case. Formulates all internal and external correspondence necessary to research and resolve case disputes and case inquiries, contacting providers and involving claims handlers as required. Communicates final decision and subsequent ramifications to claim handlers. Presents, discusses and finalizes alternative care and return to work programs with permanency ratings assigned to lost-time cases by medical providers, reinsuring the level of injury and ratings assigned are accurate and consistent with workers' compensation, state, industry and division rating standards and policies, in conjunction with the claim handler.As it relates to California: Adhere to California Nurse Practice Act, Case Management Code of Professional Conduct and Employee Code of Ethical ConductThis position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS

Registered Nurse license active and unrestricted required. Bachelor's degree in Nursing (BSN) preferred. Continuous learning required, as defined by the Company's learning philosophy. Certification or progress toward certification is highly preferred and encouraged.

EXPERIENCE

Three years active patient or clinical care experience as a Registered Nurse required. Three years workers' compensation case management, occupational health, rehabilitation or insurance experience preferred.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED

Knowledge of clinical care and jurisdictional requirements. Demonstrates the ability to be organized and efficient in prioritizing and managing assignments with minimal oversight and direction. Strong time management skills. Excellent oral and written communication, customer service, written report preparation, human relations and decision making skills are required. Demonstrates use of critical thinking, attention to detail, sound clinical judgment and assessment skills for decision making. Proficient with computer and Microsoft Windows Suite. Demonstrates courteous, professional demeanor and team spirit and the ability to work in a collaborative, effective manner.

WORKING CONDITIONS

Work is performed in an office setting with no unusual hazards. Minimal travel.

EEO/DEI

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an "at will" basis. Nothing herein is intended to create a contract.

PAY RANGE

Actual compensation decision relies on the consideration of internal equity, candidate's skills and professional experience, geographic location, market and other potential factors. It is not standard practice for an offer to be at or near the top of the range, and therefore a reasonable estimate for this role is between $63,000 and $90,400.