• Medical Case Manager- Utilization Review- Workers Compensation

    Job Location(s) US-Remote
    Job ID
    # of Openings
    Managed Care
    Job Type
    Regular Full-Time
  • Overview

    ***Note***  The hours for this position will be until 5pm or 5:30pm Pacific time which is 7-7:30pm Central time and 8-8:30pm Eastern time




    Responsible for performing Worker’s Compensation utilization review which includes prospective, concurrent, expedited and retrospective reviews to determine medical necessity and appropriateness for requested medical care using evidence based criteria. Through the discharge planning process, identify patients who have ongoing case management needs and refer these members to the Case Management team for outreach and follow up.




    Essential Duties and Responsibilities:


    • Conducts prospective, concurrent, expedited and retrospective utilization management, including inpatient services, outpatient services, surgeries and ancillary service requests.
    • Reviews all requests for treatment in accordance with preauthorization criteria
    • Evaluate treatment requests and review clinical information received with treatment protocols and guidelines, identify medical necessity and refer to the Medical Director if appropriate within the state jurisdiction timeframes
    • Review length of stay for inpatient cases when applicable;
    • Arrange alternative care services/discharge planning
    • Consult with the Medical Director as needed to review complex cases  
    • Promote cost effective health care with aligned health provider network


    Additional Functions and Responsibilities

    • Demonstrates ability to meet administrative requirements, including productivity, time management and Quality Assurance standards
    • Maintain minimum billing and established template documentation standards adhering to URAC standards and company policies and procedures
    • Reporting billing hours in accordance with case activity and billing practices
    • Maintain confidentiality- Knowledge of laws and regulations pertaining to HIPPA and PHI
    • Other job duties as assigned



    • Diploma, Associate or Bachelor’s degree in Nursing, Master’s level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred
    • Current, unrestricted Registered Nurse (RN), Licensed Practical Nurse (LPN) and or Certified Case Manager (CCM) license required
    • CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred


    To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

    • Three or more years of diverse clinical experience in acute care
    • Two or more years of Utilization Review or Managed Care experience, Worker’s Compensation background preferred
    • Knowledge of utilization management, quality improvement, discharge planning, and or cost management. 
    • Ability to solve practical problems and deal with a variety of variables. 
    • Possess planning, organizing, conflict resolution, negotiating and interpersonal skills. 
    • Excellent interpersonal skills and excellent organizational skills.
    • Ability to set priorities and work independently is essential
    • Proficient with Microsoft Office applications including Word, Excel, and Power Point



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