Professional Qualifications:

An active license to practice nursing in the state of Ohio, and, as applicable a West Virginia or other state (verification is required before job position can be offered). The license must allow the Case Manager to conduct an assessment independently as permitted within the scope of their licensure based on the standards of the discipline.

PMM requires all nurse case managers to have at least one of the following:

• Certification as a case manager from the URAC-approved list of certifications; or
• A bachelor (or higher) degree in a health or human services related field; or
• A registered nurse (RN) license.

PMM requires that case managers have one of the following URAC recognized advanced certifications application started and/or approved within four years of date of hire:

• CCM - Certified Case Manager
• CDMS - Certified Disability Management Specialist
• CMAC-Case Management Administrator, Certified
• CMC - Case Management Certified
• CRC - Certified Rehabilitation Counselor
• CRRN - Certified Registered Rehabilitation Nurse
• COHN-Certified Occupational Health Nurse
• COHN -S - Certified Occupational Health Nurse- Specialist
• RN-BC- Registered Nurse Case Manager
• ACM-Accredited Case Manager

Experience:

PMM requires all nurse case managers to have the equivalent of two (2) full-time years providing direct clinical care to consumers.

Essential Duties and Responsibilities:

• Communicates and collaborates with injured workers [IW], employers, providers, third party administrators, attorneys and the Ohio Bureau of Worker's Compensation [BWC] in order to obtain a safe RTW while meeting or exceeding Measure of Disability [MOD] benchmarks.
• Evaluates assigned claimant's physical, psychosocial, environmental, financial, and health status while establishing measurable goals appropriate for the claimant that promote the desired outcomes. Regularly reassess claimant's status and progress.
• Compare claimant's injury course to established pathways. Determine variances. Identify claimant in static or regressive status and opportunities for intervention. Make adjustments to care plan when necessary and appropriate.
• Adheres to BWC contract requirements, URAC accreditation guidelines, and all PMM policies, especially Confidentiality.
• Processes C-9 Treatment Requests within applicable program timeframes in order to provide the IW with the treatment medically necessary and appropriate for the allowed conditions and staff C-9 Treatment Requests with the Medical Director as needed.
• Coordinates with the Catastrophic Nurse Case Manager to medically manage life care plans for catastrophic claims, including onsite visits for Catastrophic claims and/or occasional Field Case Management with providers when necessary.
• Collaborates with providers to obtain current treatment plans, results of diagnostics and RTW goals.
• Obtains modified duty availability from employers and restrictions from providers.
• Identifies IWs who are potential vocational rehabilitation candidates and complete the referral process, and subsequently coordinates with the Vocational Rehabilitation Coordinator to medically manage care plans for vocational rehabilitation claims.
• Serves as a resource for staffing of difficult cases in order to establish workflows and priorities for the team as needed. This includes delegating duties to claims examiners and administrative assistants on the team in order to meet expectations and guidelines.
• Participates in educational and informational seminars as required to maintain credentials, licensures, and qualifications and to meet PMM required education pursuant to our Ohio BWC contract and URAC accreditation.
• May schedule exams, request file reviews, and appropriateness reviews as dictated by Ohio

Bureau of Workers' Compensation or Ohio or WV self- insured employers.

• Reports administrative grievances and contested treatment decisions under the direction of the Manager or designee according to the applicable Ohio Bureau Workers' Compensation Alternative Dispute Resolution and/or client specific dispute processes and established

Grievance process.

• Identifies quality issues and variances and reports to Quality Improvement staff at ProMedica Medical Management.
• Supports claims management efforts of employers (state fund and self-fund) and payers. Level of support is determined by self-funded employers or payers and can involve face-to- face meetings, tele-conferences, and creation of customized reports.
• Completes required reviews and interventions in the effort to meet Exceptional Performance quality measures and other initiatives including but not limited to DUR (Drug Utilization Review, Beers/Elderly Injured Worker, and High Risk Drug Utilization).
• Reviews medications being paid in claims to determine appropriateness and medical necessity as determined by national standard medication guidelines and as the medications relate to the BWC claim conditions. Determines if intervention is needed, collaborates with providers as part of the drug utilization review process, and educates injured workers.
• Responsible for evaluating and documenting any approved planned inpatient stay, with consideration of the BWC claim condition allowances, comorbidities of the patient, enrollment or certification status of providers, length of stay and discharge plan. Also responsible to complete Concurrent Review with the hospital during an inpatient stay. Responsible to retrospectively review all inpatient bills to ensure appropriateness of all treatments provided during the inpatient stay.
• Responsible for assisting the Billing Department with clinical review of bills and medical documentation when there are discrepancies or questions regarding appropriateness to reimburse treatment.
• To accept other duties that may be assigned.

Supervisory Responsibilities

• Accountable for the case management process. Supervises all members of the Team, which includes:
• Reviewing caseloads of Claims examiners and staffing individual claims when necessary
• Monitoring medical management of Claims examiners, including initial assessment, development of treatment plans, identification of additional diagnosis, MOD, RTW for modified duties and/or RTW with full duty, case closures and follow-up.
• Monitoring C-9 Treatment Request activity for timeliness and appropriateness
• Monitoring diaries for timeliness and completeness
• Establishing workflow and priorities for the team
• Monitoring identification of cases needing transferred to the next level of medical/case management.
• Providing information to the supervisors for non-clinical personnel regarding their performance on assigned case management duties.
• Assists with Training as needed for new incoming Case Managers

Professional Competencies

• Practices case management within the scope of their licensure as defined by the Ohio and/or West Virginia State Board of Nursing.
• Has working knowledge of workers' compensation and case management
• Has good telephone skills
• Has the ability to set priorities and organize
• Works well as a team member
• Has good interpersonal skills
• Has good writing and grammar skills
• Has the ability to manage multiple projects
• Has good computer skills