Triage Telephonic Nurse Case Manager

Key Responsibilities
Provide telephonic triage case management services at the onset of workers' compensation claims.
Conduct comprehensive clinical assessments of injured employees at the time of injury and determine appropriate levels of care.
Complete initial evaluations and required three-point contacts in accordance with state requirements and established protocols.
Assess medical appropriateness of treatment and support timely access to care.
Develop and implement initial case management care plans based on assessment findings.
Coordinate communication among injured workers, employers, providers, claims professionals, and other stakeholders.
Identify potential barriers to recovery and document findings for future case planning.
Evaluate return-to-work capabilities and facilitate modified duty discussions when appropriate.
Monitor treatment plans for compliance with state guidelines, evidence-based protocols, and client-specific requirements.
Identify potential causation concerns and communicate findings to appropriate parties.
Accurately document all assessments, contacts, medical information, and case activities within the claims management system.
Serve as a patient advocate while maintaining compliance with all legal, ethical, and regulatory requirements.
Support utilization management efforts through coordination of appropriate medical services and resources.
Participate in quality assurance initiatives and departmental projects as assigned.
Provide education and support to injured workers and their families throughout the recovery process.
Assist in training claims personnel regarding medical case management opportunities and clinical considerations.
Serve as a resource and mentor to team members as needed.

Skills, knowledge & expertise
Required Qualifications
Current unrestricted Registered Nurse (RN) license.
Minimum of 3 years of clinical nursing experience in one or more of the following:
Medical-Surgical
Orthopedics
Neurology
Critical Care/ICU
Occupational Health
Industrial Nursing
Strong clinical assessment and critical thinking skills.
Excellent verbal and written communication skills.
Ability to work independently and make sound clinical decisions.
Proficiency with Microsoft Office Suite and healthcare or claims-related systems.
Ability to manage multiple priorities in a fast-paced environment while maintaining attention to detail.

Preferred Qualifications
Previous Workers' Compensation case management experience.
Telephonic case management experience.
CCM (Certified Case Manager) designation or progress toward certification.
Experience in utilization review or managed care environments.
Familiarity with state workers' compensation regulations and treatment guidelines.
Experience working in a call center or high-volume intake environment.
Bilingual skills are a plus.

Skills & Competencies
Clinical Assessment & Triage
Workers' Compensation Case Management
Return-to-Work Coordination
Medical Documentation Review
Care Coordination
Customer Service Excellence
Critical Thinking & Problem Solving
Communication & Relationship Building
Time Management & Organization
Patient Advocacy
Regulatory Compliance
Independent Decision Making