Staff Professional-Risk Mgmt

JOB SUMMARY

The Nurse CARE Manager coordinates timely, appropriate, quality, occupational illness/injury care and follow-up to ensure early return to work and to minimize workers’ compensation losses. The NCM is responsible for conducting first level Utilization Review and coordinates subsequent levels, if necessary, as required by jurisdiction. This position is responsive to Marriott’s associates, Marriott Claims Services, business units, Risk Management and community health resources.  Quality, cost effective health services that meet the needs of the Marriott associates is a foremost concern in this position.

SCOPE/EXPECTED CONTRIBUTIONS

Scope

• Provides telephonic case management of associates with occupational illness/injuries to coordinate medical care.
• Addresses occupational injury/illness with the proactive component of aiding the associate in choosing a provider or accessing Marriott’s provider network/managed care network.
• Manages a jurisdiction of responsibility that may include multiple states.
• Conducts first level utilization review per jurisdictional requirements.
• Coordinates subsequent levels of utilization review if necessary.

Expected Contributions

Providers

• Identify and develop quality health care provider panels by building professional relationships with providers, ensuring that Marriott’s policies of transitional duty and quality care are always adhered to. 
• Maintain and update physician networks and panels.
• Collaborate with treating providers, working cooperatively for optimal outcomes.
• Arrange provider interface with business units and claims administration as needed.

Injured Workers

• Contact injured/ill worker by telephone within 48 hours following assignment.
• Coordinate care, monitor progress, and facilitate prompt return to work when released to transitional duty. 
• Serves as injured worker advocate assisting them to set goals and participate in their care.
• Recommend referral to Associate Resource Line as needed.
• Coordinate Work Hardening and Vocational Rehabilitation for injured workers per regional guidelines.
• Oversee Home Health and Field Case Managers.

Claims Services

• Collaborate with Claims department regarding case management. 
• Collaborate with UNM on utilization review issues.
• Refer catastrophic cases in coordination with claims adjuster to outside rehabilitation or field case management and closely monitor for effective progress.
• Closes files per regional guidelines. 
• Available to assist claims on informal review of litigated or lifetime medical claims to suggest course of action to move case forward. 
• Maintain case load of claims most likely to benefit from case management to meet jurisdictional needs. 

Utilization Review

• Provide initial clinical review in order to certify care and services for injured workers.
• Provide formal level 1 utilization review and document in iVOS Medical Authorization Screen.
• Coordinate subsequent levels of utilization review per jurisdictional guidelines.
• Negotiate pricing for equipment and services per jurisdictional guidelines.

Business Units

• Act as professional health resource for injured workers and managers.
• Provide triage service for business units following workplace illness/injury. 
•  Facilitate prompt return to work and transitional duty with managers.

Record Keeping/Documentation

• Provide consistent documentation that reflects all case management activities including medical, legal and ethical documentation requirements.
• Provide 90-day medical management reviews and discuss expectations and estimated length of exposure, recognize red flags and barriers to recovery.

Education, Training and Licensure

• Maintain Registered Nursing license and advanced certification(s).
• Maintain continuing education units as necessary for certifications.

Reporting

• Submit monthly and ad hoc reports as required.

 

CANDIDATE PROFILE

Experience 

• Must have at least five years nursing experience

 

Knowledge and Skills 

• Effective reasoning, analysis and decision-making skills 
• Strong negotiation skills
• Strong organization skills
• Ability to prioritize work
• Ability to meet deadlines and follow up in a timely manner
• Thorough knowledge of claims process
• Present oneself with a positive, professional demeanor.
• Communicate often with supervisor