Manager, Telephonic Nurse Case Management

Nurse Case Manager

The Nurse Case Manager serves as the clinical resource within the Risk Management & Safety team, providing telephonic nurse case management to support injured employees through the workers' compensation process from initial injury through return to work. This role applies clinical expertise to evaluate the appropriateness of medical treatment, facilitate timely access to quality care, coordinate return-to-work planning, and drive optimal outcomes for both the injured employee and the organization. The Nurse Case Manager works collaboratively with treating physicians, the Third Party Administrator (TPA), adjusters, legal counsel, managers, and HR to ensure claims progress efficiently, medical costs are appropriate, and injured employees are supported throughout recovery. This position requires a current Registered Nurse license with multistate compact privileges, strong clinical judgment, and deep familiarity with workers' compensation medical management across multiple jurisdictions.

Duties & Responsibilities

• Provide telephonic nurse case management on new and open workers' compensation claims, within established timeframes.
• Evaluate the nature and severity of injuries, review medical documentation, and assess treatment plans for clinical appropriateness, necessity, and alignment with evidence-based treatment guidelines (e.g., ODG, ACOEM, state-specific guidelines).
• Identify claims requiring nurse case management intervention based on clinical red flags, including delayed recovery, comorbidities, complex diagnoses, surgical recommendations, opioid prescriptions, and psychosocial barriers to return to work.
• Maintain ongoing communication with injured employees to monitor recovery progress, address concerns, reinforce compliance with treatment plans, and provide education on their condition and the recovery process.
• Coordinate with treating physicians to clarify diagnoses, discuss treatment plans, obtain functional capacity information, and advocate for appropriate work restrictions and modified duty accommodations.
• Facilitate peer-to-peer and utilization review referrals when treatment appears outside established guidelines, and work with the TPA and UR vendor to manage the process.
• Identify and escalate potential fraud indicators, secondary gain issues, or malingering concerns to the adjuster and Risk Management leadership with supporting clinical documentation.

Return-to-Work Coordination

• Develop and manage return-to-work plans in partnership with the injured employee, treating physician, caf/location management, and HR, with the goal of facilitating the earliest safe and medically appropriate return to productive work.
• Evaluate modified/transitional duty opportunities based on the employee's physical restrictions and available job tasks; work with location management to identify appropriate assignments.
• Monitor compliance with modified duty assignments and work restrictions; intervene when restrictions are not being accommodated or when the employee is not progressing as expected.
• Track return-to-work milestones and lost time durations; report on outcomes and identify opportunities to reduce lost-time frequency and duration across the portfolio.
• Educate supervisors and managers on the importance of early return to work, modified duty best practices, and how to support injured employees during recovery.

Medical Cost Containment

• Review medical bills and treatment requests for reasonableness and necessity; flag excessive, duplicative, or inappropriate charges to the adjuster for further review.
• Identify opportunities to redirect care to preferred provider networks, occupational health clinics, or centers of excellence when appropriate and permitted by state law.
• Monitor pharmacy utilization, particularly opioid prescriptions, compounding pharmacy usage, and formulary compliance; escalate concerns per clinical protocols.
• Evaluate surgical recommendations by reviewing medical records, recommending second opinions when warranted, and ensuring conservative treatment has been appropriately exhausted.

Claims Collaboration and TPA Partnership

• Partner with TPA adjusters on clinical strategy for open claims, including joint action planning on complex or high-exposure files.
• Participate in claim reviews and roundtable discussions with adjusters, legal counsel, and Risk Management leadership; provide clinical perspective on treatment trajectories, expected recovery timelines, and maximum medical improvement (MMI) projections.
• Support the evaluation of permanent impairment and disability ratings by providing clinical context and reviewing independent medical examination (IME) and functional capacity evaluation (FCE) reports.
• Assist in the identification and coordination of IME, FCE, and peer review referrals when warranted.
• Maintain detailed, timely clinical case management notes in the claims system, documenting all contacts, clinical assessments, action plans, and outcomes.

Data, Reporting, and Program Support

• Maintain accurate and current case management records; ensure documentation meets professional nursing standards, state regulatory requirements, and organizational expectations.
• Produce recurring and ad hoc reports on case management activity, including caseload volume, intervention outcomes, return-to-work rates, lost-time days saved, and medical cost savings.
• Identify claim trends and injury patterns from clinical observations and recommend proactive interventions to the Safety team (e.g., recurring injury types at specific locations, ergonomic risk factors, training gaps).
• Support the annual insurance renewal process by providing clinical narratives on large or complex claims as requested.
• Assist Risk Management leadership with policy development, program design, and best-practice implementation related to medical management and return-to-work programs.
• Stay current on workers' compensation medical treatment guidelines, state regulatory changes, and case management best practices across all operating jurisdictions.

Employee Advocacy and Stakeholder Communication

• Serve as a clinical resource and point of contact for injured employees, ensuring they feel supported, informed, and respected throughout the claims process.
• Communicate professionally and empathetically with all stakeholders - injured employees, families, treating providers, managers, adjusters, and attorneys.
• Provide education to location managers and HR on injury response, early intervention, the role of nurse case management, and how to support injured employees.
• Maintain strict confidentiality of all protected health information (PHI) in compliance with HIPAA, state privacy laws, and organizational policies.

Licensure

• Active, unrestricted Registered Nurse (RN) license in good standing.
• Nurse Licensure Compact (NLC) multistate license required. Must reside in an NLC compact state and hold a current multistate license, which provides practice authority in all 43+ compact jurisdictions.
• Single-state licenses for non-compact states where the company operates are preferred. The company will support the cost of obtaining and maintaining required state licenses.
• Must maintain all required licenses in active, unencumbered status throughout employment.

Certifications

• Certified Case Manager (CCM) required.
• Certified Occupational Health Nurse (COHN/COHN-S), Certified Disability Management Specialist (CDMS) and/or Certified Rehabilitation Registered Nurse (CRRN) preferred.

Experience

• 5+ years of clinical nursing experience, with a minimum of 3 years in workers' compensation nurse case management (telephonic, field, or combination).
• Demonstrated experience managing a caseload of workers' compensation claims across multiple jurisdictions, including both lost-time and medical-only claims.
• Experience with telephonic nurse case management, including three-point contact, treatment plan review, return-to-work coordination, and utilization management.
• Familiarity with evidence-based treatment guidelines (ODG, ACOEM, or state-specific guidelines) and their application in workers' compensation medical management.
• Experience working with TPAs, insurance carriers, and/or self-insured employers in a workers' compensation environment.
• Knowledge of workers' compensation regulatory frameworks across multiple states, including state-specific medical fee schedules, treatment guidelines, and return-to-work requirements.
• Experience with claims management systems (RMIS or TPA platforms) for case documentation and reporting.

Skills and Competencies

• Strong clinical assessment and critical thinking skills, with the ability to evaluate treatment appropriateness and identify barriers to recovery.
• Exceptional verbal and written communication skills, including the ability to communicate effectively with physicians, adjusters, attorneys, and injured employees across a wide range of education levels and emotional states.
• Empathetic, employee-centered approach balanced with cost-consciousness and outcome-driven decision-making.
• Ability to manage a high-volume caseload independently, prioritize competing demands, and meet documentation and follow-up deadlines without prompting.
• Strong organizational skills with meticulous attention to documentation quality and regulatory compliance.