Triage Nurse Case Manager

Department: Claims Administration & Adjusting

Employment Type: Permanent - Full Time

Location: Home United States

Reporting To: Wendy Gillmore

Compensation: $66 - $67 / year

Description

Our StoryImagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.

What’s in Store  We're on the lookout for a Triage Telephonic Case Manager to join our growing team! As a Triage Telephonic Case Manager, you will be responsible for the management and independent decision making on Workers’ Compensation medical claims at the outset of the claim. You will perform an initial assessment of the injured worker to ensure high quality of care and reduce recovery time to promote an appropriate, prompt return-to-work, according to parameters identified to meet required performance standards.

This role is a full-time, remote position. 

Key Responsibilities

• Provide triage case management in a Workers’ Compensation environment at the initial report of the claim while focusing on medical appropriateness of care to the injured worker with cost savings by coordination and utilization of all services, ensuring that as soon as medically feasible, return-to-work status is achieved
• Utilize keen clinical assessment skills to ascertain all pertinent information from the injured employee to facilitate appropriate care
• Clinically evaluate the recovery needs of an injured employee after the initial contact assessment
• Incorporate information obtained from the employer and provider into the initial plan
• Identify causal relationship issues and document the system notifying all appropriate parties
• Participate in the daily functioning of a round-the-clock intake call center, ensuring expedient care to the injured employees and being knowledgeable of all functions of the department
• Facilitate communication between the employee, the employee representative, employer, employer representative, insurer, health care provider, and the medical services organization and when authorized, any qualified rehabilitation consultant
• Identify barriers to recovery and document for future case planning
• Develop initial case-management care plan
• Appropriately document all data received from interviews, contacts and medical records in the computerized system
• Address the initial return-to-work capability with the injured worker and provider at each medical evaluation and document appropriately in computerized system
• Identify when initial treatment does not adhere to treatment guidelines and utilization criteria as determined by the state-mandated guidelines, proprietary and nationally published protocols, as well as account requirements, assuring smooth delivery of services to the injured worker
• Create, edit and/or revise correspondence in the system as necessary
• Assist with tracking protocol management for appropriate utilization and delivery of medical services; outcomes will be evidenced by patient satisfaction, appropriate delivery and quality of care and timely recovery per evidence-based criteria and clinical guidelines
• Manage the file proactively, utilizing all appropriate case management tools 
• Anticipate health needs during case management process and educate patient and family appropriately while encouraging the injured worker to participate in the recovery plan
• Maintain patient privacy by ensuring that all medical records, case specific information and provider specific information are kept in a confidential manner, in accordance with state and federal laws and regulations
• Serve as a patient advocate adhering to all legal, ethical and accreditation/regulatory standards
• Serve on appropriate committees such as the Quality Assurance and others as directed
• May negotiate fees with providers or channel cases to other vendors as appropriate
• Perform other duties as requested

Skills, knowledge & expertise

• Licensed RN with a minimum of three years of clinical experience (medical-surgical, orthopedic, neurological, ICU, industrial, or occupational)
• Workers’ Compensation and Case Management experience preferred
• Proficiency with Microsoft Office Suite and various other business software programs

Other Skills and Abilit