Provides case management or consulting services on multiple lines of business, including, but not limited to catastrophic and non-catastrophic workers' compensation claims, liability or auto/med PIP. Services may be delivered either telephonically or in person in the field. Services are provided in a timely manner and in accordance with legal statutes, policy provisions and company guidelines.
Provides medical case management services to catastrophic or other complex cases on workers' compensation, auto/med PIP or first pay bodily injury (BI) liability claims. Examples of complex cases may include, but are not limited to the following: Head injuries; Multiple traumas; Burns; Spinal cord injuries; Amputations; Chronic pain management; Medical conditions with complex ancillary or specialty services requiring extensive research of options and providers; Complex psychosocial factors requiring extensive assessment and intervention; Cases requiring a high level of negotiation and coordination with all parties to enable "stay at work" or "return to work" opportunities. Provides nurse consulting services on workers' compensation and liability claims.
Analyzes workers' compensation files and recommends actions to facilitate resolution.
Analyzes special damages on BI files and provides defense strategy recommendations to mitigate exposures.
Serves as either a consultant or case manager, but never both on the same file.
Periodically serves as a resource regarding local jurisdictional regulatory issues.
Periodically assists with special projects assigned by the Managed Care Department.
May be assigned as a mentor to a Level 1 Case Manager.
Applies the case management process of assessment, planning, implementation, coordination, monitoring and evaluation. Serves as an advocate for the injured worker, within the parameters of the applicable jurisdiction.
Develops and implements action plans on complex case management cases.
Establishes short and long term goals with assigned target dates to achieve optimal medical outcomes and minimal lost time from work.
Delivers quality services by adherence to corporate policies and procedures, best practices, client special handling instructions and applicable regulatory requirements.
Complies with corporate time and billing policies.
Maintains professional standards and ethical codes of conduct as required by the nursing license(s) and professional certification(s) held by the case manager.
Uses highly developed telephonic skills to successfully conduct services.
Follows referral criteria for involvement of field case management services.
Adheres to assignment criteria for either task or full case management.
Plans travel and work activities for efficiency, in accordance to corporate policies and best practices.
Develops relationships and knowledge of community resources to facilitate cooperation and involvement of parties. li>Maintains safety awareness and practices when working in the field environment.
Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.
Active registered nurse license(s) for Pennsylvania.
Bachelor's degree in Nursing, Healthcare and or Occupational Medicine.
Experience working with municipalities is strongly desired.
Three to five years' experience in any of the following specialties: Clinical facility in the areas of orthopedics, neurology, critical care, emergency trauma, general surgery or rehabilitation/physical medicine; Occupational health; Workers' compensation case management; General liability or Auto/med PIP.
Current professional certification(s): Certified Case Manager (CCM); Certified Disability Management Specialists (CDMS); Certified Rehabilitation Registered Nurse (CRRN); Certified Occupational Health Nurse (COHN); Legal Nurse Consultant, Certified (LNCC); Certified Legal Nurse Consultant (CLNC).
State specific registrations or certifications, as required by various workers' compensation jurisdictions.
Internal Number: 2134
About PMA Companies
Industry leader of workers' compensation, casualty insurance, and TPA & risk services with over 100 years of experience