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!