PURPOSE OF POSITION:

The primary purpose of the Case Manager is to coordinate the MCO medical management process. The Case Manager assesses plans, implements, coordinates, monitors and evaluates the care and services provided to meet the claimant's health needs. The focus of this process is to promote an early return to work. This is accomplished by accessing and implementing appropriate care options utilizing the available health resources to promote quality cost effective outcomes. Specifically, this includes the development of collaborative treatment and action plans focused on the coordination of medical care, facilitation of communication between all parties and successful completion of the plan of care for the claimant. This position entails contact with all services within AultComp MCO especially the Claim Adjuster, Clinical Editor, and Claim Coordinator, along with the BWC, providers, employers and clients.

The Case Manager will accomplish these goals by utilizing available resources, managing time effectively to accomplish critical task/projects and will use sound judgment and policy provision interpretation to apply rules and standards to produce a high volume of correctly completed casework.

RESPONSIBILITIES & EXPECTATIONS:

* Assess, plan and initiate case management plan on claimant

* Address treatment requests thoroughly and within required timeframes

* Obtain/review medical documentation required to make a decision

* Assess appropriateness of requested treatment based on Miller criteria, BWC approved nationally published and/or approved internal guidelines.

* Initiate referral to Medical Director for treatment that does not meet medical necessity according to guidelines for final determination, direction on appropriate treatment plan and need for peer review.

* Communicate whether reimbursement for the requested treatment has been approved/denied, including service requested, body location, quantity of treatments, treatment dates, rationale/national clinical guidelines and recommended alternative treatment, if applicable, in the decision letter.

* Complete claim status, allowed ICD-9 codes, approval/denial, begin/end dates, MCO name, MCO number, date, phone number, and signature on the C9.

* Document medical information and authorization clearly and notifies all parties to the claim.

* Maintains contact with medical providers, claimant and employer

* Coordinate, monitor and evaluate cases, documenting all case activity.

* Provide educational support for claimant, medical provider, and employer regarding the workers' compensation process, BWC/AultComp MCO guidelines and the importance of early return to work.

* Maintain confidentiality of all information and assures that confidential files are secured.

The above statements reflect the general duties considered necessary to describe the principle functions of the job as identified, and shall not be considered as a detailed description of all the work requirements that may be inherent to this position.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

QUALIFICATIONS:

* Current, active, unrestricted RN licensure in State of Ohio and a minimum of three years clinical practice experience and practice case management.

o Two years full-time equivalent providing direct clinical care.

* A bachelor's degree or higher in a health related field is preferred. Certification as a case manager or willingness to attain certification

* Previous experience utilizing spreadsheet, database or related software preferred.