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UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

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Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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Assistant Clinical Case Manager - Workers' Compensation

  • Job ID: 477823344
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: WKP Comm WC Claims Admin
  • Location: 600 Grant St, Pittsburgh PA 15219
  • Union Position: No
  • Salary Range: $20 to $33.22 / hour

Description

UPMC Health Plan is seeking a full-time Assistant Clinical Case Manager - Workers' Compensation to support the UPMC Workpartners Commercial Claims Department!

The Assistant Clinical Case Manager will primarily work from home, but there will be required meetings and/or office time periodically at the U.S. Steel Tower in Downtown Pittsburgh. This role will work standard hours, Monday through Friday!

Workpartners administers both occupational and non-occupational disability management programs for UPMC and external clients, and is a leading provider of integrated health and productivity solutions as part of UPMC Insurance Services Division! Workpartners' Nurse Case Managers are responsible for assisting the Claims staff and clients in the medical and disability case management of all assigned cases.

The Assistant Clinical Case Manager will support the growing caseloads of the Commerical team, working hand-in-hand and communicating with physicians and other providers, members, adjusters, and other staff. Responsibilities include, but are not limited to, medical oversight support, assisting with return to work, claim closure, supporting and presenting on claim reviews, writing independent medical evaluation letters to physicians, and working both independently and as a cohesive team member.

The ideal candidate for this position will have exceptional written and verbal communication skills! Any previous experience with Workers' Compensation, disability management, risk management, insurance, safety management, case management, and/or occupational medicine is preferred. Licenses in multiple states or the willingness to become licensed in other states is a major plus!



Responsibilities:

GENERAL RESPONSIBILITIES

  • In conjunction with the claims adjusters and treating medical personnel, 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 a successful return to work, and collaborating 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, 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.

SPECIFIC RESPONSIBILITIES

  • Utilizing the essential case management activities of assessment, planning, implementation, coordination, monitoring, evaluation, outcomes, and general case manager activities shall primarily include, but are not limited to the following:
    • Participate as part of a multidisciplinary team in the management of specific account programs assigned.
    • Provide Best in Class Nurse Case Management on all claims assigned.
      • These claims may include lost-time claims, medically complex, and/or long-term medical only/restricted medical only claims.
  • Reviews initial injury reports for assessment of injury and determines the level of case manager involvement that will be needed.
  • Acts as a Triage Nurse for the Clinical Case Management Team.
  • Documents all information in a timely manner in the claims system and maintains diary system and/or escalates cases to Clinical Case Management, if needed.
  • Provides updates to claims adjusters, as needed.
  • Sends Work Status to Employers/Insureds.
  • Monitors employees' care and progress during an injury or illness with regard to ODG guidelines to determine if escalated clinical case management involvement is needed if falling outside recovery expectations.
  • Utilizes standardized duration resources to guide return to work timelines and communicates with treating physicians in seeking clarification if injured employees fall outside anticipated durations.
  • Assists with coordination of appointments for panel treatment, PT, and Diagnostics with OCCM.
  • Follows up for appointment dates once referral is made.
  • Ensures that the provider has the required documentation, medical reports, diagnostic test results, and/or job description, prior to the scheduled examination.
  • Proactively communicates via phone or fax to the treating physician prior to scheduled appointments any pertinent information that may impact the treatment plan.
  • Maintains system-wide competencies/behaviors.
  • Provides medical resources for the claims staff and functions as part of the medical escalation process as per Nurse Case Manager criteria.
  • Interacts with the Medical Director as per escalation process.

 

Qualifications

  • LPN or Medical Assistant, OR minimum of 1 year of clinical experience, OR equivalent with current professional and education experience.
  • BSN preferred or equivalent professional and educational experience required in lieu of RN licensure.
  • Experience in Workers' Compensation, disability management, risk management, insurance, safety, and/or case management experience is preferred.
  • Previous occupational medicine experience preferred.
  • Excellent organizational and communication skills required.


Licensure, Certifications, and Clearances:

  • Act 34
  • Preferred: Licensed Practical Nurse (LPN)


UPMC is an Equal Opportunity Employer/Disability/Veteran

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