Job Description
Telephonic Nurse Case Manager Department: Claims Administration & Adjusting
Employment Type: Permanent - Full Time
Location: Home United States
Reporting To: Shaunna Jones
Compensation: $78,000 - $83,000 / year
Description Our Story Imagine being part of a team that's not just shaping the future but actively driving it. At
Davies North America , we're at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.
We are seeking an experienced Telephonic Nurse Case Manager with a background in Florida Workers' Compensation to join our growing team. In this role, you will be responsible for independently managing medical claims, coordinating care, and facilitating timely, cost-effective treatment for injured workers. The goal is to ensure quality medical outcomes while supporting a safe and medically appropriate return-to-work.
This position requires a minimum of 1 year experience of either Florida Occupational Health or Florida Worker's Compensation. Key Responsibilities - Provide telephonic case-management in a Workers' Compensation environment. Focus on medical appropriateness of care to injured worker with cost savings by coordination and utilization of all services, ensuring that as soon as medically feasible, return-to-work status is achieved, along with increase in productivity.
- Facilitate communication between the employee, the employee representative, employer, employer representative, insurer, health care provider, the medical services organization and when authorized, any qualified rehabilitation consultant, to achieve the goals
- Clinically evaluate the recovery needs of an injured employee after the initial contact assessment. Incorporate into the initial plan information obtained from the employer and provider.
- Identify barriers to recovery and formulates an action plan to overcome these barriers.
- Provide ongoing assessment of health and medical records.
- Monitor and audit health provider ensuring licensure and appropriate care.
- Monitor vendor performance, ensuring quality service.
- Develop case management care plan, tracks and modifies appropriately
- Appropriately document all data received from interviews, contacts and medical records in the computerized system.
- Address the return-to-work capability with the injured worker and provider at each medical evaluation. Document appropriately in computerized system. Obtain a job description from the employer and presents to the provider if necessary. Verify disability against approved guidelines, questioning variances.
- Manage the file adhering to treatment guidelines and utilization criteria as determined by the state-mandated guidelines, proprietary and nationally published protocols, as well as account requirements, assuring smooth delivery of services to injured workers or third party claimants.
- Create, edit and/or revise correspondence.
- Evaluate treatment plans and documents outcomes. Track protocol management for appropriate utilization and delivery of medical services. Outcomes will be evidenced by patient satisfaction, appropriate delivery and quality of care and timely recovery per evidenced based criteria and clinical guidelines. Return-to-work outcomes and length of disability outcomes are calculated and monitored according to criteria as published in the Official Disability Guidelines.
- Manage the file pro-actively, utilizing all appropriate case management tools.
- Develop alternative treatment plans when necessary. Demonstrate the ability to accommodate changes on the case-management process for delivery of a more refined and efficient system.
- Identify the need for utilization review procedures to claims, such as triggers that might indicate a potential barrier to recovery. UR tools include physician advisor review, pre-certification, pre-authorization, concurrent review and retrospective review of bills and reports. Communicate the findings determined in utilizing these tools and document appropriately.
- Anticipate health needs during case-management process and educate patient and family appropriately. Encourages the injured worker to participate in the recovery plan.
- Review medical bills for appropriateness and forward bills to Bill Review/Cost Containment Organization for adjudication.
- Maintain patient privacy by ensuring that all medical records, case specific information and provider specific information are kept in a confidential manner, in accordance with state and federal laws and regulations.
- Serve as a patient advocate adhering to all legal, ethical and accreditation/regulatory standards.
- Serve on appropriate committees such as Grievance, Quality Assurance and others as directed.
- May negotiate fees with providers or channel cases to other vendors as appropriate.
- Maintains contracted State of Florida performance standards for case management.
- May train claims staff on the identification of medical case management opportunities.
- May provide leadership of lower graded staff in the department.
- Perform other duties as needed.
Skills, knowledge & expertise - At least one year's experience handling Florida Workers' Compensation case management or Florida Occupational Health experience (contractual requirement).
- Maintains knowledge of current trends, standards and law changes.
- Must be self directed and able to work independently.
- Ability to effectively operate a personal computer and related claims and business software.
- Good communication skills, both oral and written. Team player. Good attendance. Good customer service skills.
- RN with a minimum of three years clinical experience (medical-surgical, orthopedic, neurological, ICCU, industrial or occupational).
- Proof of current State Licensure.
- Bilingual - fluent English/Spanish helpful.
Benefits Benefits At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes:
- Medical, dental, and vision plans to ensure your health and that of your family.
- A 401k plan with employer matching to help you build a secure financial future.
- Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
- Paid holidays.
- Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.
Diversity and Inclusion Davies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard.
Job Tags
Permanent employment, Full time, Temporary work,