Sr. Medical Case Manager

Job Description To provide effective case management services in an appropriate, cost effective manner. Provides medical case management service which is consistent with URAC standards and CMSA Standards of Practice and Broadspire Quality Assurance (QA) Guidelines to patients/employees who are receiving benefits under an Insurance Line including but not limited to Workers' Compensation, Group Health, Liability, Disability, and Care Management. Responsibilities Reviews case records and reports, collects and analyzes data, evaluates injured worker/disabled individual's medical status, identifies needs and obstacles to medical case resolution and RTW by providing proactive case management services. Render opinions regarding case costs, treatment plan, outcome and problem areas, and makes recommendations to facilitate case management goals to include RTW. Demonstrates ability to meet administrative requirements, including productivity, time management and QA standards, with a minimum of supervisory intervention. May perform job site evaluations/summaries to facilitate case management process. Facilitates timely return to work date by establishing a professional working relationship with the injured worker/disabled individual, physician, and employer. Coordinate RTW with injured worker, employer and physicians. Maintains contact and communicates with claims adjusters to apprise them of case activity, case direction or secure authorization for services. Maintains contact with all parties involved on case, necessary for case management the injured worker/disabled individual. May obtain records from the branch claims office. May review files for claims adjusters and supervisors for appropriate referral for case management services. May meet with employers to review active files. Makes referrals for Peer reviews and IME's by obtaining and delivering medical records and diagnostic films, notifying injured worker/disabled individual and conferring with physicians. Utilizes clinical expertise and medical resources to interpret medical records and test results and provides assessment accordingly. May spend approximately 70% of their work time traveling to homes, health care providers, job sites and various offices as required facilitating RTW and resolution of cases. Meets monthly production requirements and quality assessment (QA) requirements to ensure a quality product. Reviews cases with supervisor monthly to evaluate files and obtain directions. Upholds the Crawford and Company Code of Business Conduct at all times. Demonstrates excellent customer service, and respect for customers, co‑workers, and management. Independently approaches problem solving by appropriate use of research and resources. May perform other related duties as assigned. Qualifications Bachelor's Degree in a health-related field is preferred. Associates or diploma in nursing also accepted. Three years of Workers' Compensation case management with ability to independently coordinate a diverse caseload ranging in moderate to high complexity. Demonstrated ability to handle complex assignments and ability to work independently is required. Effective oral and written communication skills are required. Thorough understanding of jurisdictional WC statutes. Advanced knowledge to exert positive influence in all areas of case management. Advanced communications and interpersonal skills in order to conduct training, provide mentorship, and assist supervisor in general areas as assigned. Highly skilled at promoting all managed care products and services internally and externally. Active RN home state licensure in good standing without restrictions with the State Board of Nursing. Minimum of 1 nationally recognized Certification from the URAC list of approved certifications. Must be able to travel as required. Individuals who conduct initial clinical review possess an active, professional license or certification: To practice as a health professional in a state or territory of the U.S.; and With a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review. Must maintain a valid driver's license in state of residence. About Us Why Crawford? Because a claim is more than a number — it’s a person, a child, a friend. It’s anyone who looks to Crawford on their worst days. And by helping to restore their lives, we are helping to restore our community – one claim at a time. At Crawford, employees are empowered to grow, emboldened to act and inspired to innovate. Our industry-leading team pioneers new solutions for the industries and customers we serve. We’re looking for the next generation of leaders to take this journey with us. We hail from more than 70 countries and speak dozens of languages, reflecting the global fabric of the audience we serve. Though our reach is vast, we proudly operate as One Crawford: united in purpose, vision and values. Learn more at When you accept a job with Crawford, you become a part of the One Crawford family. Our total compensation plans provide each of our employees with far more than just a great salary Benefits Pay and incentive plans that recognize performance excellence Benefit programs that empower financial, physical, and mental wellness Training programs that promote continuous learning and career progression while enhancing job performance Sustainability programs that give back to the communities in which we live and work A culture of respect, collaboration, entrepreneurial spirit and inclusion Crawford & Company participates in E-Verify and is an Equal Opportunity Employer. M/F/D/V Crawford & Company is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at Crawford via‑email, the Internet or in any form and/or method without a valid written Statement of Work in place for this position from Crawford HR/Recruitment will be deemed the sole property of Crawford. No fee will be paid in the event the candidate is hired by Crawford as a result of the referral or through other means. #J-18808-Ljbffr Crawford & Company