Telephonic Nurse Case Managers

CCS has contracted with one of the largest commercial property and casualty insurance company domesticated in Georgia and a leading underwriter of workers’ compensation insurance in the Southeast.

They work through a network of local independent insurance agents to deliver workers’ compensation and general liability insurance products tailored to the needs of the home building community.

We have an immediate need for experienced Telephonic Nurse Case Managers. Nurse Case Managers have the option to telecommute or work from home. Nurse Case Managers are required to come into the office for specified training period, monthly and quarterly meetings.

Primary responsibilities include: Act as a liaison between all parties involved in work-related injuries. Control costs and length of disability through the monitoring of all medical aspects of the claim by implementation of the nursing process which includes assessment, planning, coordination, intervention and evaluation.

Manage case load (typically 60 - 80 telephonic cases). Provide initial contact on all assigned lost time files within 24 hours and provide complete early intervention report within 48 hours. Input pertinent data and recommendations electronically on all assigned cases and bills. Assist in the pre-certification process, recommending any diagnostic tests and procedures for medical review and medical necessity. Coordinate/schedule IME or second opinion appointments as needed, as well as all authorized medical treatments and appointments.

Maintain contact with the injured worker, employer, and adjuster as often as needed, to ensure that the treatment plan is understood and improvement is being made and maintain communication between all parties involved in treatment plan, i.e. physician, therapist, etc.

Contact and obtain approval for injured worker contact on all represented cases as requested by the Adjuster. Consult with Supervisor on all cases that have been recommended for referral to a contract rehabilitation nurse. Make recommendations for referral to field case management on all cases meeting criteria. Provide medical updates after each appointment, including review of progress, change in work status and change in treatment plan. Provide early intervention on all assigned cases. Provide monthly MR status reports addressing medical progress, treatment plan, RTW/Vocational issues and projected date of MMI.

Assist in negotiating pricing for medical equipment, supplies and/or treatment as needed. Coordinate return to work with adjuster and employer. Provide recommendations based on the assessment of medical reports, evaluating for appropriate care and the claimant’s progress to recovery. Keep abreast of any changes in procedures or handling of cases as well as Workers’ Compensation State laws.

Position Requirements: College degree in nursing required. BSN preferred. Registered Nurse license required. Certification preferred – CCM, CRRN, COHN, or CDMS. 5 years of clinical nursing experience required. 1 year of workers’ compensation case management experience required. 2 + years of workers’ compensation experience preferred.

Utilization Review experience preferred. The successful candidate will be organized and detail oriented. This person will have excellent verbal and written communication skills as well as strong customer service, analytical and problem solving skills. For more details. Qualified individuals should send a resume and cover letter to hr@CostContainmentSolutions.com or fax to (800.867.1522).

CCS is an Equal Opportunity Employer. Employment is contingent upon successful completion of a background investigation. Pre-employment drug screening required. No recruiters or agencies without a previously signed contract.

Nurse Case Mgr

Performs care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs. Essential duties may include, but are not limited to:
 

Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
 

Coordinates internal and external resources to meet identified needs. Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
 

Negotiates rates of reimbursement, as applicable.

Assists in problem solving with providers, claims or service issues. Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cares for discussion at Care Conferences and participates in interdepartmental and/or cross brand workgroups. This position may require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and will function as preceptor for new care management staff. Also actively participates in department audit activities and performs other related duties as required. Performs other duties as assigned.

Qualifications:

Requires bachelor’s degree or higher in a health related field and licensure as a health professional, or certification as a care manager, or unrestricted RN licensure in applicable states and 5 years clinical experience. Bachelor’s degree in nursing, certification in appropriate product/service, clinical or care management experience appropriate to demands desired. Requires knowledge of health insurance/benefits. Requires knowledge of care management assessment technique, provider community, and community resources.
 

Three years experience in home health/discharge planning preferred. Must have strong oral, written and interpersonal communication skills, PC skills to include word processing, spreadsheet, and database applications, organizational and problem-solving skills, and decision-making skills. The following are level distinctions that are not required for posting. This level manages the most complex cases, may participate in department audit activities, serve as preceptor for new associates and participate in or lead projects with cross-functional teams.

The successful candidate will be organized and detail oriented. This person will have excellent verbal and written communication skills as well as strong customer service, analytical and problem solving skills.

For more details. Qualified individuals should send a resume and cover letter to hr@CostContainmentSolutions.com or fax to (800.867.1522).

CCS is an Equal Opportunity Employer. Employment is contingent upon successful completion of a background investigation. Pre-employment drug screening required. No recruiters or agencies without a previously signed contract.

Sr. Claims Adjuster

SUMMARY:

Investigate, evaluate, reserve, negotiate and settle assigned claims in accordance with Best Practices. Provide quality claim handling and superior customer service on assigned claims, while engaging in indemnity & expense management. Promptly manage claims by completing essential functions including contacts, investigation, damages development, evaluation, reserving, litigation management, and disposition. A minimum of seven years claim experience preferred, with three of those years handling litigated files. 

PRIMARY DUTIES:

Timely coverage analysis and communication with insured based on application of policy information to facts or allegations of each case. Consult with Unit Manager on use of Claim Coverage Counsel.
Investigate each claim through prompt contact with appropriate parties such as policyholders, accounts, claimants, law enforcement agencies, witnesses, agents, medical providers and technical experts to determine the extent of liability, damages, and contribution potential.

Take necessary statements. Identify resources for specific activities required to properly investigate claims such as outside claim representatives, nurse consultants, and fire or fraud investigators and to other experts. Request through Unit Manager and coordinate the results of their efforts and findings.

Verify the nature and extent of injury or property damage by obtaining and reviewing appropriate records and damages documentation.

Keeps effective diary management system to ensure that all claims are handled timely. At required time intervals, evaluate liability & damages exposure, and establish proper indemnity & expense reserves. Utilize evaluation documentation tools in accordance with department guidelines.
Responsible for prompt and proper disposition of all claims within delegated authority. Negotiate disposition of claims with insureds and claimants or their legal representatives. Recognize and implement alternate means of resolution.

May manage litigated claims. Develop litigation plan with staff or panel counsel, track and control legal expenses. Assure cost-effective resolution.

Attend depositions, mediations, arbitrations, pre-trials, trials and all other legal proceedings, as needed.

Maintain claim files, have an effective diary system, and document claim file activities in accordance with established procedures.

Update appropriate parties as needed, providing new facts as they become available, and their impact upon the liability analysis and settlement options.

Recognize cases based on severity protocols to be referred to next level claim handler or Major Case Unit and refer on a timely basis.

Appropriately deal with information that is considered personal and confidential.
Compliance with Claim Department’s ’Best Practices’.

Fulfill specific service commitments made to certain accounts, as outlined in Special Account Communication (SAC) instructions, and inquires from agents and brokers.

Handles moderate to complex litigation
Manage litigation expenses and payout.
Leverages relationships with plaintiff’s counsel

EDUCATION/COURSE OF STUDY:
College degree or equivalent in business discipline preferred

CERTIFICATES/DEGREES:
State license where applicable & continuing education

OTHER:
Advanced level knowledge and skill in claims and litigation.
Basic working level knowledge and skill in various business line products.
Strong negotiation and customer service skills

The successful candidate will be organized and detail oriented. This person will have excellent verbal and written communication skills as well as strong customer service, analytical and problem solving skills. For more details. Qualified individuals should send a resume and cover letter to hr@CostContainmentSolutions.com or fax to (800.867.1522).

CCS is an Equal Opportunity Employer. Employment is contingent upon successful completion of a background investigation. Pre-employment drug screening required. No recruiters or agencies without a previously signed contract.

RN - Medical Bill Audit Specialist

Responsible for review, analysis and reduction of national medical utilization and compensation. Under administrative direction, exercises discretion and independent judgement to provide a thorough professional review of complex medical billing, potentially including written and verbal interpretation of that review if a case goes to trial.

May involve assisting with special projects. · Reviews and audits medical bills and re-evaluations from multiple states to assess compensation and medical necessity as well as negotiates appropriate payment. ·

Makes decisions and resolves issues regarding medical bill disallowances and disputed charges with outside facilities and providers both verbally and in writing. Includes applicable workers´ compensation statutory requirements and fee schedule(s) in decision-making process. Documents conversations and agreements in Powertrak and sends confirmation /verification letters. ·

Acts as a resource to Bill Review and communicates appropriate payment amounts. ·

Develops and maintains relationships and partnerships with medical providers and facilities.

Handles provider and/or client correspondence requiring medical expertise and decision-making regarding bill payment. · Works with Corporate Provider Fraud Unit to identify possible medical services and/or billing fraud.

Prepares for and attends workers´ compensation trials as necessary.

Maintains records, identifies and addresses trends in billings practices.

Conduct on-site training for Bill Review staff.

Processes pre-authorization reviews and authorizes payment for treatment in compliance with jurisdictual statutes and company standards.

Consistently and accurately documents interventions and rationale for decisions in the appropriate claim system screen.

May assist with special projects and assume other responsibilities as assigned. · Ability to meet production standard of an average of 40 bills per day

Willingness to complete assigned duties timely.

Professional Development · Maintains clear and active RN license in state(s) employed. · Pursues continuing education to maintain RN active status, in technical areas related to Workers´ Compensation injuries, illnesses and bill auditing.

Possesses or pursues additional professional designations such as CIRS, CCM, CRRN. · Maintains knowledge of Workers´ Compensation statues and changes in multiple states through self-development program including research, reading and attending classes or seminars. · Maintains strong written and verbal communication skills.

Education, Skills and Experience Requirements · Active and clear RN license. · 3-5 years of clinical experience in Orthopedics, ER, Occupational Health and/or Neurology/Neurosurgery. · 3-5 years of national Workers´ Compensation Bill Audit experience, including an understanding of utilization/bill review, claims, managed care processing and knowledge of workers´ compensation laws/fee schedules in most states. · 1-2 years of group health managed care experience preferred. · Flexibility in adjusting to additional information and a sense of fairness in determining allowances.

Excellent negotiation, problem solving and analytical skills and strategies. · Excellent interpersonal and communication skills - oral and written. Must be able to communicate effectively with all levels of staff. · Experience with Windows (3.1 or higher), Microsoft Office, and Excel.

The successful candidate will be organized and detail oriented. This person will have excellent verbal and written communication skills as well as strong customer service, analytical and problem solving skills. For more details. Qualified individuals should send a resume and cover letter to hr@CostContainmentSolutions.com or fax to (800.867.1522).

CCS is an Equal Opportunity Employer. Employment is contingent upon successful completion of a background investigation. Pre-employment drug screening required. No recruiters or agencies without a previously signed contract.