TCM/FCM Hybrid Nurse Case Manager

As our Nurse Case Manager, you will coordinate care for injured or disabled individuals, including high-risk, high-cost, and complex cases. The role applies professional nursing judgment and case management principles to assess needs, facilitate appropriate treatment, monitor progress, support functional recovery and return-to-work goals, and promote quality, cost-effective outcomes through collaboration with clients, patients, employers, providers, attorneys, and other stakeholders.

In this job, you will:

Maintain a mix caseload of field and/or telephonic case management files. Typical caseload of 30-40 cases.

Establish collaborative relationships and serve as an intermediary among clients, injured or disabled individuals, employers, providers, attorneys, and other involved parties.

Manage a caseload of high-risk, high-cost, and complex cases by assessing clinical, functional, psychosocial, and vocational needs.

Assess, coordinate, implement, monitor, and evaluate individualized care plans using principles of medical necessity, appropriateness of care, case management, and managed care.

Promote quality, cost-effective care across the health care continuum to support optimal function and safe, timely return to work when appropriate.

Assess injury severity, extent of disability, treatment plans, functional abilities, and physical job requirements to develop return-to-work strategies and help manage future medical exposure.

Track and report case management activity and maintain organized, timely, and accurate clinical documentation of interactions, interventions, barriers, outcomes, and communications.

Respond to written and telephonic inquiries regarding case status and document relevant case information in Rising systems and client claims systems, when applicable.

Adhere to applicable state, national, accreditation, departmental, and client-specific quality standards, guidelines, policies, procedures, and reporting requirements.

Escalate potential clinical, operational, service, or compliance concerns to the appropriate supervisor as they become evident.

• Assist with URAC accreditation activities and the maintenance of related policies and procedures.
• Provide professional nursing insight to Rising Medical Bill Analysis and other internal teams, as requested.
• Current, active, unrestricted RN license in primary residence state and preferably in a compact state
• California RN license a plus
• Full Time – 9:00am CST to 5:30pm CST, with the ability to flex time based on the jurisdiction
• Strong computer skills required – Microsoft Suite (Outlook, Excel, Word, etc.)
• 3-5 years of case management experience with 1-2 years of specific worker’s compensation NCM experience
• Experience with Workers’ Compensation, liability, or disability claims
• Medical bill review experience with Workers’ Compensation, Auto, or Health Insurance carriers is preferred
• The ability to maintain confidentiality of all information, policies, and procedures
• The ability to set priorities and work both autonomously and as part of a team
• Demonstrated sensitivity to culturally diverse people and situations
• Well-developed time management, organization, and prioritization skills
• Knowledge of utilization management, case management, and healthcare provided throughout the health continuum
• Excellent oral and written communication skills with a heavy focus on customer-service
• The ability to gather data, compile information, and prepare summary reports
• Strong interpersonal and conflict resolution skills
• Experience in a fast-paced, multi-faceted environment
• Demonstrated persistence and attention to detail
• The ability to stay calm during stressful situations
• Having your CCM, and/or any other insurance/workers’ compensation certifications is a huge plus!
• Professional Nursing degree (ASN, BSN)
• Competitive base salary, profit sharing, 401k matching, generous time off, and career growth opportunities
• A relaxed, yet upbeat, work environment
• Rising was named a Top Workplace in the healthcare industry for 2023! Check out our profile here: Rising Medical Solutions, Inc Profile (topworkplaces.com)
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If you are ready to join a team of professionals dedicated to making a difference and making lives better, please apply today!