Sr Medical Case Manager (Finance)

• Great Work Life Balance!

• Quarterly Bonus Program!

• Free CEU's for licenses and certificates

• License and national certification reimbursement

This is a work from home position requiring local field case management travel to cover the Houston, TX region.

• RN degree required
• Bilingual RN preferred
• National Certification such as CCM, CRC, COHN, CRRC required
• Prior Workers Compensation Case Management preferred

To provide quality case management services in an appropriate, cost effective manner. Provides medical case management service which is consistent with URAC standards and CMSA Standards of Practice and Quality Improvement Guidelines to patients/employees who are receiving benefits under an Insurance Line including but not limited to Workers' Compensation, Group Health, Liability and Disability.

• Bachelor's Degree in a health-related field is preferred. Associates or diploma in nursing also accepted.
• Three years of Workers' Compensation case management with ability to independently coordinate a diverse caseload ranging in moderate to high complexity.
• Demonstrated ability to handle complex assignments and ability to work independently is required.
• Effective oral and written communication skills are required.
• Thorough understanding of jurisdictional WC statutes.
• Advanced knowledge to exert positive influence in all areas of case management.
• Advanced communications and interpersonal skills in order to conduct training, provide mentorship, and assist supervisor in general areas as assigned.
• Highly skilled at promoting all managed care products and services internally and externally.
• Based on federal, state, or local law, this position may require you to be fully vaccinated for COVID-19.
• Active RN home state licensure in good standing without restrictions with the State Board of Nursing.
• Minimum of 1 nationally recognized Certification from the URAC list of approved certifications.
• Must be able to travel as required.
• Individuals who conduct initial clinical review possess an active, professional license or certification:
  • To practice as a health professional in a state or territory of the U.S.; and
  • With a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review.
• Must maintain a valid driver's license in state of residence.

• May assist supervisor/manager in review of reports, staff development.
• Reviews case records and reports, collects and analyzes data, evaluates client's medical and vocational status and defines needs and problems in order to provide proactive case management services.
• Demonstrates ability to meet or surpass administrative requirements, including productivity, time management, quality assessment (QA) standards with a minimum of supervisory intervention.
• Facilitates a timely return to work date by establishing a professional working relationship with the injured worker/disabled individual, physician and employer. Coordinates return to work with injured worker/disabled individual, employer and physicians.
• May recommend and facilitate completion of peer reviews and IME's by obtaining and delivering medical records and diagnostic films notifying patients.
• Manages cases of various product lines of at least 3-4 areas of service (W/C, Health, STD, LTD, Auto, Liability, TPA, Catastrophic, Life Care Planning). Specifically, the case manager should be experienced in catastrophic cases plus 2-3 additional types listed above.
• Renders opinions regarding case cost, treatment plan, outcome, and problem areas and makes recommendations to facilitate rehabilitation case management goals to include RTW.
• May review files for claims adjusters and supervisors.
• May perform job site evaluations/summaries. Prepares monthly written evaluation reports denoting case activity, progress and recommendations in accordance with state regulations and company standards.
• May obtain referrals from branch claims office or assist in fielding phone calls for management as needed.
• Maintains contact and communicates with insurance adjusters to apprise them of case activity, case direction or receive authorization for services. Maintains contact with all parties involved on case, necessary for rehabilitation of the client.
• May spend approximately 70% of work time traveling to homes, health care providers, job sites, and various offices as required to facilitate return to work and resolution of cases.
• May meet with employers to review active files.
• Reviews cases with supervisor monthly to evaluate file and obtain direction.
• Upholds the Crawford and Company Code of Business Conduct at all times.
• Demonstrates excellent customer service, and respect for customers, co-workers, and management.
• Independently approaches problem resolution by appropriate use of research and resources.
• May perform other related duties as assigned.