Job Description

Paramount Health Care, a ProMedica Health Plan, offers insurance products across six Midwest states. This Ohio-based company, headquartered in Toledo, has more than 685 employees dedicated to serving their health plan members.

Paramount offers Medicare Advantage and Marketplace Exchange health plans for individuals and families. Paramount maintains accreditation by the National Committee for Quality Assurance (NCQA) for their HMO and Medicare Advantage products.

In addition, Paramount has a full complement of insurance products for employers of any size, including medical, dental, vision and workers\' compensation, as well as vocational rehabilitation, life-care planning and wellness.

As a part of ProMedica, Paramount is driven by ProMedica\'s mission to improve your health and well-being. ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. Paramount strives to provide an exceptional experience to every member. For more information about Paramount, please visit our website at paramounthealthcare.com.

REPORTING RELATIONSHIPS/SUPERVISORY RESPONSIBILITIES

Direct reporting to the department Administrative Director with matrix reporting to the Lead, Clinical Manager regarding State-Funded Case Management, and the SI Clinical Director for Self-Insured Case Management. This position is a working Team Lead that has daily oversight of other RN Case Managers.

POSITION SUMMARY

Nurse Case Managers communicate with injured workers [IW], employers, providers, third-party administrators, attorneys, and the Ohio Bureau of Worker\'s Compensation [BWC] to obtain a safe RTW while meeting or exceeding Measure of Disability [MOD] benchmarks

ACCOUNTABILITIES

• Communicates and collaborates with injured workers [IW], employers, providers, third-party administrators, attorneys, and the Ohio Bureau of Worker\'s Compensation [BWC] to obtain a safe RTW while meeting or exceeding Measure of Disability [MOD] benchmarks. Adheres to the BWC contract requirements, URAC accreditation guidelines, and all HMS policies, especially Confidentiality.

• Evaluates assigned claimant\'s physical, psychosocial, environmental, financial, and health status while establishing measurable goals appropriate for the claimant that promote the desired outcomes. Regularly reassess the claimant\'s status and progress. Compare claimant\'s injury course to established pathways. Determine variances. Identify claimant in static or regressive status and opportunities for intervention. Adjust care plan when necessary and appropriate.
• Processes C-9 Treatment Requests within applicable program timeframes to provide the IW with the treatment medically necessary and appropriate for the allowed conditions and staff C-9 Treatment Requests with the Medical Director as needed. Collaborates with providers to obtain current treatment plans, results of diagnostics, and RTW goals.
• Coordinates with the Catastrophic Nurse Case Manager to medically manage life care plans for catastrophic claims, including conducting onsite visits for Catastrophic claims and/or occasional Field Case Management with providers when necessary.
• Obtains modified duty availability from employers and restrictions from providers. Identifies IWs who are potential vocational rehabilitation candidates and complete the referral process, and subsequently coordinates with the Vocational Rehabilitation Coordinator to medically manage care plans for vocational rehabilitation claims. May schedule exams, request file reviews, and appropriateness reviews as dictated by Ohio Bureau of Workers\' Compensation or Ohio or WV self-insured employers.
• Serves as a resource for staffing of difficult cases to establish workflows and priorities for the team as needed. This includes delegating duties to claims examiners and administrative assistants on the team to meet expectations and guidelines.
• Participates in educational and informational seminars as required to maintain credentials, licensures, and qualifications and to meet HMS required education according to our Ohio BWC contract and URAC accreditation. Identifies quality issues and variances and reports to Quality Improvement Staff at Health Management Solutions.
• Reports administrative grievances and contested treatment decisions under the direction of the Manager or designee according to the applicable Ohio Bureau Workers\' Compensation Alternative Dispute Resolution and/or client-specific dispute processes and established Grievance process. Reviews medications being paid in claims to determine appropriateness and medical necessity as determined by national standard medication guidelines and as the medications related to the BWC claim conditions. Determines if intervention is needed, collaborates with providers as part of the drug utilization review process, and educates injured workers.
• Supports claims management efforts of employers (state fund and self-funded) and payers. The level of support is determined by the employer or payers and can involve face-to-face meetings, conferences, and the creation of customized reports.
• Completes required reviews and interventions in the effort to meet Exceptional Performance quality measures and other initiatives including but not limited to DUR (Drug Utilization Review, Beers/Elderly Injured Worker, High-Risk Drug Utilization.
• Responsible for evaluating and documenting any approved planned inpatient stay, with consideration of the BWC claim condition allowances, comorbidities of the patient, enrollment or certification status of providers, length of stay, and discharge plan. Also responsible to complete Concurrent Review with the hospital during an inpatient stay. Responsible for retrospectively reviewing all inpatient bills to ensure the appropriateness of all treatments provided during the inpatient stay. Responsible for assisting the Billing Department with the clinical review of bills and medical documentation when there are discrepancies or questions regarding appropriateness to reimburse treatment.
• Supervisory Responsibilities
• Accountable for the case management process. Supervises all members of the Team, which includes:

• Reviewing caseloads of Claims examiners and staffing individual claims when necessary
• Monitoring medical management of Claims examiners, including initial assessment, development of treatment plans, identification of additional diagnosis, MOD, RTW for modified duties and/or RTW with full duty, case closures, and follow-up.
• Monitoring C-9 Treatment Request activity for timeliness and appropriateness
• Monitoring diaries for timeliness and completeness
• Establishing workflow and priorities for the team
• Monitoring identification of cases needing to be transferred to the next level of medical/case management.
• Providing information to the supervisors for non-clinical personnel regarding their performance on assigned case management duties.
• Assists with training as needed for new incoming Case Managers
• Other duties that may be assigned.

Job Requirements

REQUIRED QUALIFICATIONS

Education: A bachelor\'s degree in a health or human services related field

Skills: Strong computer, organization, and communication skills; Working knowledge of workers\' compensation and case management. Strong collaboration, leadership, and interpersonal skills. Working knowledge of workers\' compensation and case management processes and filings.

Years of Experience: Minimum of two years providing direct clinical care to consumers.

License: Active, unrestricted OH and/or WV RN license issued

Certification: Certification as a case manager from the URAC-approved list of certifications approved within four years of the date of hire (RNs employed before policy implementation on 01/01/12 had three years from that date to obtain advanced certification):

• CCM - Certified Case Manager
• CDMS - Certified Disability Management Specialist
• CMAC - Case Management Administrator, Certified
• CMC - Case Management Certified
• CRC - Certified Rehabilitation Counselor
• CRRN - Certified Registered Rehabilitation Nurse
• COHN - Certified Occupational Health Nurse
• COHN -S - Certified Occupational Health Nurse- Specialist
• RN-BC - Registered Nurse Case Manager
• ACM - Accredited Case Manager

PREFERRED QUALIFICATIONS

Education:

Skills:

Years of Experience: Minimum of four years providing direct clinical care to consumers.

WORKING CONDITIONS

Personal Protective Equipment: None

Physical Demands: None

ProMedica is a mission-based, not-for-profit integrated healthcare organizational headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica

Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact employment@promedica.org

Equal Opportunity Employer/Drug-Free Workplace

Employee Exemption Type

Exempt

Job Type

Full Time

Budgeted Hours / Pay Period

80

Shift Type

Days

Shift Hours

8 hours

Weekends

N/A

On-call Requirements

Call Not Required

Additional Schedule Details

ProMedica