Clinical Case Manager (RN) – Workers' Compensation

UPMC’s Health Plan is hiring a Clinical Case Manager to support an external client. This is a predominantly remote position but may require onsite presence in downtown Pittsburgh as needed if requested by the client (subject to change in the future if needed).

Work Partners administers both occupational (Workers’ Compensation) and non-occupational disability management programs for UPMC and external clients. Work Partners’ Nurse Case Managers are responsible for assisting the claims staff and clients in the medical and disability case management of all assigned cases. In conjunction with the claims adjusters and treating medical personnel, the NCM will monitor each claim with the objective of assisting an employee in receiving any needed medical care as a result of their injury/illness, identifying physical capabilities that allow the employee to return to work as soon as is medically possible following standardized disability guidelines, identifying any known barriers that would prevent successful return to work, and collaborate in conjunction with treating provider(s) and claims staff to develop strategies to bring each claim to an anticipated successful close. In order to meet this objective, the NCM must be familiar with the worlds of occupational and non-occupational medicine; and with the medical details of each injury/illness, including the current treatment and the anticipated return to work date.

Responsibilities:

• Provide `Best in Class’ Nurse Case Management on all claims assigned. These claims may include 1) all lost time claims; 2) all restricted medical only claims remaining open after 30 days; 3) any other complicated claim assigned by the supervisor; 4) all referrals from external client(s).

• Provide medical resource for the claims staff and function as part of the medical escalation process as per Nurse Case Manager criteria. Interact with the Medical Director as per escalation process.

• Assist as needed with coordinating appointments with panel provider or other providers. Ensure that the provider has the required documentation, medical reports, diagnostic test results, and/or job description, prior to the scheduled examination.

• Proactively communicate via phone or fax to the treating physician prior to scheduled appointments any pertinent information that may impact the treatment plan

• Utilize standardized duration resources to guide return to work timelines and communicate with treating physicians in seeking clarification if injured employees fall outside anticipated durations.

• Keep claims adjusters or non-occupational client apprised of an employee’s progress and medical status (maintaining HIPAA privacy standards for client interaction). Document all information in a timely manner in the claims system and maintain diary system.

• Review medical information and provide feedback to claims staff with regards to the causal relationship of the work injury to the medical evidence provided. Actively monitor employees’ care and progress during an injury or illness and interact with appropriate panel provider/treating physician to assure understanding of the treatment plan o Prepare in whole or in part (along with the claims adjusters) letters to physicians, letters regarding Independent Medical Evaluations, or other documentation requiring a medical perspective

• Chart, file and maintain accurate and confidential medical records. Enter applicable data into the computer system and prepare weekly/monthly reports as defined by client guidelines.

• Schedule Independent Medical Examinations as approved by the claims team. Notify employee and legal counsel if applicable of the date and times. Forward relevant information to the physician and review the IME report when received. Discuss with appropriate claims staff. 

• Review liability files at the client’s request. Review peer/record review reports upon receipt. Discuss with appropriate claims staff. 

• Review reports: weekly, monthly and quarterly to evaluate the effectiveness of the medical delivery system, and to identify trends and cost containment opportunities.

• Target specific high-cost drivers and develop strategies to minimize the impact of such on the overall cost of the program