Provide telephonic medical case management of lost time and complex medical claims for Workers´ Compensation within the rules, regulations, and ethical standards established by the Departments of Insurance and Labor AHCA.
Job Specifics Complete assigned training to become familiar with company policy and procedure applicable to the assigned Case Management Unit.Adhere to the company´s workers compensation managed care arrangement (WCMCA) policies and procedures including utilization of approved network providers.Perform medical case management functions that include writing detailed medical assessments, formulating specific treatment plans, directing medical treatment and modalities, and assisting in timely return to work and injury resolution.Triage new claims with designated staff.Review referred claims for priority handling, determination of medical treatment plan, medical necessity, causal relationship and compensability. Act as a liaison between insured, injured employee and medical providers.Communicate with MCC regarding referrals to specialists and authorize referrals to specialist. Also authorize hospitalizations, diagnostic procedures, pharmacy, DME, and second medical opinions. Access GEO referral system to identify primary care and specialist providers to injured workers.Coordinate and monitor appropriate use of ZENITH Field Case Management a outside vendors.Update and document medical treatment plan in conjunction with provider and Claims Representative. Act as a consultant to Case Management Unit on medical issues.Attend large loss and educational rounds.Assist in setting and maintenance of medical reserves.Review hospital or provider files to investigate over utilization on quality issues.Refer files to the Clinical Supervisor for peer review on quality issues.Assist in resolution of injured worker and provider informal grievances.Make referrals to network physicians and network providers, documentingreasons for any out of network referrals.Update medical status as necessary.Education, Skills and Experience RequirementsCalifornia LicenseThree years clinical experience.Experience in orthopedics, neurology, psychiatry, rehabilitation, or workers compensation.Experience in case management in either a clinical or insurance setting.Maintain appropriate continuing education credits to maintain state license.Complete ZENITH training and performance assessments at set standards.