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Description
Review initial liability disability claims to determine extent and impact of insured's medical condition, medical restrictions and limitations and expected duration. Handles more complex cases and cases involving largest reserves. Act as resource for peers. May assist with training, case supervision or case review and mentoring/coaching team members to achieve high outcomes on cases. Applies clinical training and knowledge to the assessment, management and coordination of disability cases. Provides claim office staff with technical insight and training to assist in identifying cases that will benefit from claim management. Works with employees, policyholders and health care providers to facilitate and/or coordinate a strategy to expedite the employee's return to work. RN license and 3-5 years clinical experience required. Bachelor's degree and case management or other applicable certification (CRC or CDMS) preferred. Work experience in disability management, utilization management, discharge planning, return to work planning or case management. Experience with short or long term disability preferred. Strong analytical, problem solving and decision making skills. Strong computer skills required. Knowledge of workers' compensation regulations. Excellent communication, time management, and organizational skills.
Responsibilities
Assesses the medical, vocational, financial, and behavioral needs of referred, ill/injured persons via combination of face-to-face, telephonic and written correspondence with a variety of parties, within the scope of the license/certification. Case management assessment and evaluation - gathering relevant medical and vocational information and data; interpreting same to develop a plan; requires interaction with the ill/injured person and specific goal-setting. Coordination of services based upon case-specific local, state and federal regulations as well as policy coverage pertinent to the case
Proposes and implements a cost effective vocational/medical case management plan to the referral source in the form of an initial report produced via personal computer. Modifies plan as needed based on case progress. Requires ability to negotiate with multiple parties.
Coordinates and implements the approved plan to successful completion and reports on the status via a progress/re-assessment report produced on the personal computer. Follow-up and evaluation of persons success relative to case plan; re-assessing case plan as necessary to ensure successful outcomes
Demonstrates appropriate outcomes measured during the life of a case against long and short-term goals; outcomes are summarized at the time of case closure the aim to maximize the persons outcomes and maximize medical status and return to work status. The aim is to return the person, as close as possible, to his/her pre-illness/pre-injury status.
Maintains accurate documentation of records on each case including assessment, goals, barriers, billing, savings and demographic data.
Requires knowledge of ethics, rights to privacy, confidentiality and advocacy for the ill/injured person; knowledge of community resources, ADA, HIPPA and appropriate legislation required; ability to negotiate
Adheres to established quality standards and customer special instructions.
Establishes and maintains professional, collaborative relationship with providers and customers.
Ability to assume one or more of these duties:
Assist with training new case managers, including acting as a preceptor to new hires.
Provide service marketing.
Provide utilization review of assigned files
Complete special projects as assigned.
Ability to interact with local sales and/or account managers as appropriate to meet customer needs. Participates in customer visits as needed.
Car travel required to expedite field case management activities.
Ability to negotiate level of care, intensity and duration with provider(s).
*Caseloads vary depending on client need and case complexity and method of delivery (field based vs. telephonic). Caseload size is adjusted based upon other duties. Average caseload size for a FT FCM is 25-30; for a FT TCM, 70-90.
Qualifications
Ideal candidate must live in Orange County California Area.
Education
Bachelor's degree or higher in a health-related field (such as nursing, physical therapy, occupational therapy, medical social work, vocational rehabilitation or counseling) preferred along with appropriate licensure where required, i.e., R.N. license for nurses, state counselor licensure for counselors, licensed physical therapist, etc.
Or
Certification as a case manager
Or
RN license (Associates or Diploma degree nurse) with three (3) years full-time clinical experience.
Certification
Certification is recommended and professionally encouraged. Approved certifications included Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Certified Occupational Health Nurse (COHN), Certified Rehabilitation Registered Nurse (CRRN) or Certified Rehabilitation Counselor (CRC). Certification as Certified Legal Nurse Consultant (CLNC), Certified Life Care Planner (CLCP) and Certified Nurse Life Care Planner (CNLCP) will also be considered as long as the individual meets the basic URAC education and experience requirements for case management staff.
Knowledge and Experience
Staff must practice within the scope of their license (i.e., RN license, counselor license, etc.) and any code of ethics associated with any certifications; staff must maintain current licensure/certification
Registered nurses must have minimum of three nursing experience in the one of following areas: ICU/CCU, trauma, spinal cord injuries, medical/surgical, orthopedics, neurology, or rehab.
Registered nurse with an alternate bachelor's degree such as psychology, social, counseling, etc., may be considered for a dual role as a medical/vocational field specialist if skills and experience allow.
A non-RN candidate, i.e., medical social worker, must have three (3) years medical case management experience in a clinical setting
Minimum of three years case management experience preferred
Three years experience working in a disability compensation system such as workers' compensation, short or long term disability preferred.
Bilingual skills, both verbal and written, as required based upon the geographic area and unit need where the case manager will be located
Pay Benefits Work Schedule
CIGNA offers a competitive compensation and comprehensive benefits package including health and wellness benefits, 401k plan, and work/life balance programs, as well as opportunities for career growth and development.
How To Apply
We encourage you to complete all questions on the candidate profile if you wish to be considered for this opportunity.
Details:
Job Id:
18694798
Posted / Updated:
4/7/2010 3:40:40 AM
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