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Managed Care NCM
Ref No.: 17-00148
Category: Permanent Placement
Location: Orange, California
Managed Care Case Manager (RN)
Location: Orange, CA
SUMMARY
This position requires an individual experienced in Workers' Compensation, Case Management and Utilization Review, and other similar services, who, under minimal supervision can independently analyze incoming referrals, communicate at a clinical level with all clients, providers, claims examiners, and other stakeholders to a claim, while meeting contracted client requirements, and state regulatory requirements.
ESSENTIAL DUTIES AND RESPONSIBILITIES includes the following:
  • Working to provide direct support to organization's Physicians conducting various services in support of the claim
  • Obtaining and Assessing necessary medicals for appropriate product needs; utilization review, pharmaceutical, discharge planning
  • Coordinating essential workflow with Pharmacy Benefit Management partnerships, and other designated service vendors
  • Collaborating with Utilization Review team for seamless processes in maintaining jurisdictional requirements
  • Serving as active team member in URAC accreditation responsibilities, as needed
  • Functioning to provide quality driven data entries for various clinical products
  • Utilizing a multi-disciplinary team approach to achieve client satisfaction
  • Assist the Medical Director and AVP of Clinical Services in directing service outcomes
QUALIFICATIONS
  • Experience in the Workers' Compensation arena; and understanding of Evidence Based Criteria
  • Strong Organizational skills; able to work independently; and able to prioritize projects to meet necessary deadlines
  • Ability to identify and resolve problems in a timely manner, while able to gather and analyze information.
  • Ability to demonstrate accuracy and thoroughness, monitor own work to ensure quality and apply feedback to improve performance
  • Good Communication skills; problem solving; and critical thinking
  • Ability to mentor other non-clinical team members to assist in growth and learning within the department
EDUCATION AND EXPERIENCE
  • Current unrestricted Nursing License
  • College education, Bachelor's Degree preferred
  • 5 years or more Workers' Compensation experience, with an emphasis in the Case Management arena
LANGUAGE SKILLS
  • English required, bilingual preferred