Telephonic Medical Case Management (Workers' compensation)

Tristar Insurance; South Carolina; Hybrid; USD 65,000 - 85,000; Full time

Job summary

Tristar Insurance seeks a Medical Case Manager to deliver telephonic case management in a workers’ compensation setting, coordinating resources and cost-effective options to support individualized treatment goals and return-to-work placement.

Responsibilities include assessment, care planning, data review, and ongoing coordination with providers, claimants, and employers, while maintaining HIPAA compliance and high-quality documentation.

Qualifications

• RN/LPN/CCM license required or equivalent.
• Three+ years of clinical experience in acute care.
• Two+ years in medical case management or workers’ compensation.
• Knowledge of utilization management and cost control.
• Familiarity with discharge planning and QA processes.
• Strong problem solving, planning and negotiation skills.
• Proficient with MS Office applications.

Responsibilities

• Provide telephonic case management for workers’ compensation patients.
• Assess, plan, implement and coordinate care with all stakeholders.
• Document assessments and develop clinical case plans.
• Coordinate contact with providers, claimants and examiners.
• Review records, analyze data and determine care needs.
• Monitor appointments, address RTW and treatment plan issues.
• Maintain confidentiality per HIPAA and PHI regulations.

Education

RN/LPN/CCM license required

CCM/CPHM certifications preferred

Clinical experience in acute care

Medical case management experience

Utilization management knowledge

Quality improvement

Discharge planning

Cost management

Problem solving

Planning and organization

Negotiation and interpersonal skills

MS Office (Word, Excel, PowerPoint)

Job description

Position Summary

The medical case manager provides telephonic case management in a workers’ compensation environment coordinating resources and cost‑effective options on a case‑by‑case basis to facilitate quality individualized treatment goals and return‑to‑work placement.

Essential Duties and Responsibilities

• Provide telephonic outreach for assessment and follow up for case communication and coordination, including assessing, planning, implementing, and coordinating care.
• Conduct and document initial assessment with injured worker, employer, and provider, maintaining regular contact with all parties to facilitate communication and formulate a clinical case plan.
• Coordinate contact with provider, claimant, RTW contact, and claims examiner.
• Review case records and reports, collect and analyze data, evaluate client’s medical status, and define needs and problems to provide proactive case management services.
• Assess medical records for appropriateness of treatment and level of care; refer to the Medical Director if appropriate within established timeframes.
• Facilitate timely return‑to‑work date coordinating RTW with claimant, employer, and physicians.
• Maintain contact and communicate updated activity with all parties involved with the case.
• Telephonically monitor medical appointments of the injured worker to address RTW, current treatment plan, and identify potential issues; negotiate treatment plan with treating physician.
• Demonstrate ability to meet administrative requirements, including productivity, time management, and Quality Assurance standards.
• Maintain minimum billing and established template documentation standards adhering to URAC standards and company policy.
• Report billing hours in accordance with case activity and billing practices.
• Maintain confidentiality; knowledge of HIPAA and PHI laws and regulations.
• Other job duties as assigned.

Qualifications

• Diploma, Associate, Bachelor’s degree in Nursing, Health, or Human Services field or equivalent related experience preferred.
• Current, unrestricted Registered Nurse (RN), Licensed Practical Nurse (LPN) and/or Certified Case Manager (CCM) license required.
• CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred.
• Three or more years of diverse clinical experience in acute care.
• Two or more years of medical case management or managed care experience; workers’ compensation background preferred.
• Knowledge of utilization management, quality improvement, discharge planning, and/or cost management.
• Ability to solve practical problems and deal with a variety of variables.
• Planning, organizing, conflict resolution, negotiating, and interpersonal skills.
• Excellent interpersonal, organizational, and prioritization skills; ability to work independently.
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint).