Texas RN - Nurse Case Manager/UR Nurse

Medical Case Management Nurse

AvonRisk is the nation's leading specialty risk manager for self-insured organizations, uniting respected regional leaders in workers' compensation, liability, managed care, and risk management across 32 states. With nearly 700 professionals and brands including Intercare, InterMed, George Hills, and AS&G Claims Administration, we're a people-focused, operations-driven organization that prioritizes reasonable caseloads, strong training, collaborative teams, and expert support. We invest in tools and workflows that reduce frictionnot increase volumeand create real career paths for professionals who want to grow their careers or move into leadership. At AvonRisk, you're part of a team that values good judgment, curiosity, and accountability, and gives you the support to succeed.

The Medical Case Management nurse is a hybrid position for case management and utilization in Texas. The case manager ensures achievement of maximum medical and disability improvement through early, proactive intervention. These activities emphasize quality care through coordination of cost-effective appropriate treatment. These objectives are obtained by communication with the primary care physician, the injured worker, the employer, claims adjustor and all other parties involved in facilitating the best possible outcome for the given claim. The Hybrid role of nurse case management and utilization review

• Domiciled in Texas, performing Texas reviews and cases. The Medical Case Management nurse is aware the claims adjustor is ultimately responsible and accountable for the outcome of these claims and no intervention is undertaken without their authority and direction. The Medical Case Management nurse is seen as the patient's advocate and as the representative of the insured and must be able to satisfy the needs of all concerned while being objective and effective. The Medical Case Management Nurse is also responsible for performing utilization review based on medical necessity.

Essential Duties and Responsibilities:

• All claims assigned are triaged within 24 hours of assignment.
• Initial contacts (employee, employer, Primary Care Physician) and documentation are to be completed on all files referred within 72 hours (when applicable).
• When needed disability management is initiated to identify anticipated lost time and coordinate the return to work process.
• The Medical Case Management nurse will address all medical issues for the claim assigned and coordinate as needed to insure optimum outcome with timely and appropriate medical care.
• Will receive and review referrals for treatment for medical appropriateness of treatment plan based on accepted evidence based guidelines and best practices, according to state specific rules and regulations.
• All claims assigned are triaged within 24 hours of assignment.
• Initial contacts (employee, employer, Primary Care Physician) and documentation are to be completed on all files referred within 72 hours (when applicable).
• When needed disability management is initiated to identify anticipated lost time and coordinate the return to work process.
• The Medical Case Management nurse will address all medical issues for the claim assigned and coordinate as needed to insure optimum outcome with timely and appropriate medical care.
• Will receive and review referrals for treatment for medical appropriateness of treatment plan based on accepted evidence based guidelines and best practices, according to state specific rules and regulations.
• Will identify the medical diagnosis and treatment plan; validate diagnosis and corresponding algorithms of care.
• Will review treatment protocols and make recommendation using local, regional, and national recognized evidence base guidelines such as MTUS, ACOEM, MCG, ODG, state specific treatment guidelines, as well as documentation provided by the PTP.
• Will evaluate for over-utilization of treatment requests inconsistent with evidence based guidelines and when possible, negotiate with provider to amend or withdraw the treatment request when appropriate.
• Will refer potential non-certified cases to peer clinical reviewers.
• Will perform utilization review on concurrent requests. Follow up when appropriate.
• Arrange peer to peer contact with the peer reviewer as needed and as requested by the requesting treating provider.
• Assist in the notification process for the non-certification issued by the physician reviewer
• Will direct and maximize the utilization of PPO/MPN networks.
• Pre-authorization of all appropriate inpatient and outpatient procedures.
• Will communicate with the claims examiner, providers, attorneys and any other auxiliary provider regarding UR determination in the prescribed given time frame followed in written within 24 hours.
• Will summarize medical records and all pertinent information presented with recommendation to Physician Advisor and/or prepare questions on complex cases for peer or third party review.
• Will work closely with the client, claims handler, nurse case manager and supervisor, and take directions when needed.
• May be required to direct non-clinical tasks to non-clinical staff
• All Utilization Review for California will be performed in compliance with Labor Code and the California Code of Regulations. Utilization Review in any state will follow and be in compliance with their State Rules & Regulations related to Utilization Review.
• Participate in a quality management program meeting and project for at least 5% of average hours worked.
• Oversight of non-clinician tasks; available to non-clinical administrative staff while performing initial screening
• Maintain awareness of potential compromise in a patient's safety for each review. Refer to proper authority.
• Uses plain language to communicate (written and verbal) with injured workers, claims examiners, and clients.

Competency:

• Must be self-motivated with the ability to multi task and adapt to changing work priorities
• Must have strong organizational skills with attention to details
• Must have strong time management skills
• Must be able to work well with a variety of co-workers, clients, vendors, and others
• Must be able to follow directions

Qualification Requirements:

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. The individual must possess an active RN license in California, with a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience:

• Current and valid California RN
• Minimum of 1 year clinical experience
• Should be familiar with California Workers' Compensation, Managed Care experience/Utilization Review experience recommended
• Completion of IEA CA 10 class within 1 year of employment if no prior workers' compensation experience.

Salary Range: $78,000 -$87,000

The salary range listed is an estimate. Actual compensation will be determined based on several factors such as a candidate's experience, qualifications, skill set, and work location.

Benefits:

• Comprehensive medical, dental, and vision benefits
• Company contributions to HSA and FSA plans
• Employer paid life and disability insurance
• 401(k) with company match
• Paid time off (PTO) and company paid holidays
• Learning and development opportunities that support real career advancement
• Employee assistance resources and a supportive culture that values balance and wellbeing

We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

Pursuant to the Los Angeles and San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest or conviction records.

AS&G Claims Administration