Job Description
Healthcare - Full-time
Nurse Case Manager Job Description (updated 12/24)
• Attend physician appointments to determine relatedness or provide coordination of care. If the Case Manager cannot attend scheduled physician appointment see Physician Appointment Attendance Protocol
• Arranges for prompt and appropriate medical treatment of an injured worker by qualified providers (choice of providers as per regulations); Schedules appointments to avoid delays in treatment by primary care physicians, specialists or ancillary services
• Assists the treating physician in developing a written treatment plan for the injured worker, including the identity and scope of treatment by any other providers to which referrals have been made. Work with the medical providers to track progress and to modify the treatment plan as necessary until maximum medical improvement is achieved
• Obtains medical reports and required work status forms. Ensures all parties receive appropriate reports
• Facilitate authorization/certification of procedures, diagnostic testing, physical therapy/occupational therapy and durable medical equipment as per regulations to ensure appropriate treatment is not delayed
• Cooperates with the treating physician to obtain a full or conditional release to return to work before injury becomes a lost time claim; Work with the treating physician to update any conditions as medical treatment progresses
• Assesses the injured worker and his/her support system and family; Makes appropriate referrals throughout the continuum of care including educational, financial, and psychological or other human services as indicated
• Coordinates with the employer to develop a modified duty job for the injured worker who cannot immediately return to his/her full pre-injury employment; The job must be consistent with any physical restrictions assigned by the treating doctor; Educates the employer on the tangible and intangible benefits of accommodating the injured worker to keep him in the work force
• Where a return to work with the same employer is not possible, provide vocational services to the injured worker to identify vocational goals and develop an early return to work plan
• Maintains constant contact with the adjuster assigned to the file through telephone calls, EMAIL and written reports. For each customer be aware of the limits of decision-making authority delegated by the adjuster to the case manager and respect these limits. Satisfy the documentation and reporting requirements of each customer.
• Organizes and review medical records to identify specific medical issues; Provides information and recommendations to appropriate parties
• Acts as an advocate for the injured worker with all parties while maintaining the injured worker’s privacy and safety; Adheres to HIPAA confidentiality policies and procedures. Follows ethical, legal, and regulatory standards
• Participates in the collection of outcome information and improvement process to determine the impact of case management activities on timely injury recovery, medical treatment, return to work, claim costs, and both injured worker and client satisfaction. The result achieves desirable outcomes for all
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PO Box 888657, Grand Rapids MI 49588
Phone 616.540.2869
Fax 616.469.1060
• Maintains continuing education requirements per state license requirements. Maintains an updated and working knowledge of workers’ compensation and federal laws that impact the delivery of health care and return to work
• Become proficient in the software used in the department
• Contribute to the success of the company and its posture toward customer service by a positive and professional attitude and by understanding and responding to the needs of our direct and indirect customers; Follows ethical, legal, and regulatory standards
• Performs other duties as assigned
• Works with injured parties with Auto No Fault and General Catastrophic Medical. EDUCATION:
• MA/ BS / BA in Nursing or Associates Degree in Nursing from accredited school with Equivalent Work Experience and a CCM, CIRS, CRRN, COHN or other related designation or;
• Current Nursing license and/or certification
• CCM required based on state guidelines. EXPERIENCE:
• Three or more year’s workers compensation /Auto No Fault case management experience or related field KNOWLEDGE: SKILLS/ABILITIES
• The ability to work effectively with minimal direct supervision
• The ability to plan and use time effectively
• The ability to work as a member of the team
• Must be computer literate
• Keyboard typing and dialing of telephone require hand dexterity and the repetitive use of finger movement
• Due to the nature of the position, sitting in a sustained position for prolonged periods may be necessary
• Vision must be adequate to view the computer screen
• This may include occasional air travel and overnight stays
• Must have the ability and willingness to travel for task and/or field case management visits if within assigned geographic areas
• Must possess a valid driver’s license; Must provide proof of insurance
REQUIRED TASKS PER CLIENT
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Attend physician appointments
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Routine team meetings to ensure that providers (counselors, physicians, therapists, DME, nursing care, etc) are all functioning as a cohesive team and Case Managers are aware and overseeing that all care, equipment and services are properly managed and reported to insurer
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Monthly reports due by or before the 1st or each month
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Ensure that Advocate information is up to date
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Utilize Case Management Goals as “task list”
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After every physician appointment, send Physician Appointment Summary (report) to insurer with physician orders
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Monthly client visits minimum (this may be phone, virtual meeting if appropriate)
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PO Box 888657, Grand Rapids MI 49588
Phone 616.540.2869
Fax 616.469.1060
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Ensure prescriptions are filled on time and refills are not needed. Assist patient PRN with pharmacy, insurance or obtaining refill from physician
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Set up transportation for clients (or ask Administrative Assistant to set up)
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Attend (or get coverage) for PCP, PM&R, Specialists
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Send Physician Summary Reports and orders to; Insurance, providers along with orders
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Schedule team meetings with multidisciplinary team every 1-2 months
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Get updates from homecare, therapy, DME monthly (if new equipment or service)
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Get medical records/clinic notes, Send medical records to specialists
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Report monthly to attorney and contact
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Medical bills
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Check for expired (or expiring) forms; HIPAA, orders, prescription refills, guardianship/conservator
Physician Appointment Attendance Protocol Attend scheduled appointments to determine and document relatedness to injury and/or provide care coordination. If the assigned Nurse Case Manager cannot attend the physician appointment the following protocol must be followed;
• Attempt to reschedule the appointment with the physician if possible, within the same calendar week (if client is able and agreeable)
• Contact RMC Case Managers via email group text to see if appointment can be covered, if this is not successful
• Contact RMC Senior Case Manager assigned to see if appointment can be covered, if this is not successful
• Notify client you are unable to attend the appointment. Provide them with a list of things you plan to discuss at the appointment and physician orders you are planning to request. Client can call you if you are available via phone during that time.
• Contact physician office, ask to speak to the Office Manager or Nurse line. Notify them you are the Nurse Case Manager and unable to attend. Notify them you will be sending a faxed letter with an update and prescription requests.
• Fax physician office report and request for physician orders
• Follow up with client after appointment
• Follow up with physician office after appointment (to get requested documentation/after visit summary) or assign task to Admin team Client Contact Protocol
• Minimum bi-weekly contact with client or guardian to ensure care needs are being met and provide update on care coordination needs.