Performs clinical occupational case management duties in support of Workers′ Compensation by reviewing and analyzing medical reports to determine if requested treatments, surgeries, etc., fall within specific Medical Treatment Utilization Schedule (MTUS) and Official Disability Guidelines (ODG) parameters; recommending either authorization or providing data to outside vendor for determination; and advising claims adjusters in arranging discharge planning, which will result in decreased medical and disability costs, reduced claim duration, and increased patient and client satisfaction.

• Manages cases by communicating with clients, medical providers, attorneys, employers, and adjusters to ensure appropriate treatment is provided and employees are returned to work in a timely manner

• Assesses disability status, makes recommendations and identifies appropriate resources

• Gathers and coordinates medical evidence for evaluation of functionality and makes assessments on restrictions and limitations; identifies anticipated length of disability based on accepted guidelines

• Determines whether a requested treatment is medically appropriate, and if yes, approves treatment

• Coordinates with outside utilization review (UR) vendor if it appears treatment is not medically appropriate and coordinates with employee's physician

• Ensures that Division of Workers' Compensation (DWC) timeframes are adhered to for UR

• Prioritizes which reviews must be done first in order to maintain compliance with both UR guidelines and protect patient outcomes

• Coordinates discharge planning if requested by adjuster

• Arranges home healthcare if adjuster requests/requires assistance

• Ensures that UR Assistant's data entries are correct and adjusts as needed; explains corrections made to UR Assistant and ensures that future entries are consistently done in correct format

• Provides regular ongoing reports and correspondence to the Claims Adjuster managing file via hard copy, e-mail, phone, fax, or in person

• Prepares documentation according to jurisdictional and departmental guidelines within a timely manner

• Consults with Claims personnel on case management issues and applies effective case management interventions

• Addresses causality as requested and refers to appropriate medical resources

• Acts as a resource by providing information and answering questions for claims staff and other agency employees; interprets medical reports if adjuster needs assistance with medical terms, abbreviations, etc.

• Provides information on new medical procedures or medications if they may impact department

• Contributes to ensuring that the Equal Employment Opportunity (EEO) policies and programs of Metro are carried out

  
  May be required to perform other related job duties

Knowledge of (defined as a learned body of information that is required for and applied in the performance of job tasks)

• Theories, principles, and practices of case management nursing and workers′ compensation insurance

• Medical terminology, medical conditions, injuries, and health care delivery systems

• Applicable federal, state, and local regulations, such as California Code of Regulations, American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines, and Occupational Disability Guidelines

• Medical office, hospital, and other medical environments

• Research and report preparation methods

• Applicable business software applications

Skill in (defined as the proficient manual, verbal, or mental utilization of data, people, or things)

• Evaluating medical evidence and making assessments on work restrictions and limitations

• Analyzing situations, identifying problems, and recommending solutions

• Exercising sound judgment and creativity in making decisions

• Effectively and sensitively communicating with all levels of employees internal and external to Metro

• Interacting professionally and maintaining cooperative work relationships with various levels of Metro employees and outside representatives, such as physicians and other members of the medical community

Ability to (defined as a present competence to perform an observable behavior or produce an observable result)

• Self-manage case referrals on a daily basis

• Review and interpret medical records

• Work effectively, independently, and in a team setting

• Meet tight time constraints and deadlines

• Understand, interpret, and apply laws, rules, regulations, policies, procedures, contracts, budgets, and labor/management agreements

• Prepare comprehensive reports and correspondence

• Handle highly confidential information

• Compile and analyze complex data

• Read, write, speak, and understand English

A combination of education and/or experience that provides the required knowledge, skills, and abilities to perform the essential functions of the position. Additional experience, as outlined below, may be substituted for required education on a year-for-year basis. A typical combination includes:

Education

• Bachelor′s Degree in Nursing, Health Administration, Hospital Administration, Health Services Administration, Medical Technology, or a medical related field

Experience

• Three years of relevant experience performing a wide variety of clinical nursing and case management duties in a hospital, home health, or workers compensation environment; some positions in this class may require specialized experience in area of assignment

Certifications/Licenses/Special Requirements

• A valid California Class C Driver License or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions

• Registered Nurse in the State of California

The physical demands described are representative of those that must be met by the employee to successfully perform the essential functions of this job. Metro provides reasonable accommodation to enable individuals with disabilities to perform the essential functions.

Working Conditions

• Typical office situation

• Close exposure to computer monitors and video screen

Physical Effort Required

• Sitting at a desk or table

• Operate a telephone or other telecommunications device and communicate through the medium

• Type and use a keyboard and mouse to perform necessary computer-based functions

• Standing

• Walking (distance 5' to 100')

• Communicating through speech in the English language required