With a high level of medical expertise and under minimal supervision, provide medical case management for medically complex workers’ compensation claims. Serve as medical resource for claims staff and provide guidance and information on specific claims.
Provide medical expertise to claim examiners and IE’s relating to diagnosis, treatment plan and related expenses. May facilitate identifying and obtaining appropriate care as medically needed. Work with team member to bring medical issues to an expedient and effective resolution. (40%)
Research analyze and provide treatment plans with evidence-based best practices. Analyze medical claims management issues with other claims professionals through communication, coordination and facilitation of information to assist with return to work efforts, and negotiate appropriate treatment plans with medical providers. (40%)
Effective communications with IE’s, medical providers and others; provide education, consultation, and assist with RTW efforts. (20%)
Conducts file reviews for early intervention of claims focusing on medical provider records.
Interviews the injured employee and collaborates with other team members to facilitate and identify appropriate medical care.
Provide medical expertise relating the IE’s diagnosis, treatment plan and medical expenses to reported injury/occupational disease.
Assist team members with bringing medical issues to an expedient and cost effective resolution.
The MCM typically works claims that are up to two years old, may be involved in older claims for a brief period if special procedures are being performed and the claims examiner requests special assistance.
The MCM may be involved in older claims if an External Case Manager is assigned to the claim.
Research, analyze and provide treatment plans with evidence-based best practices.
Analyze medical claims management issues with other claims professionals through communication, coordination and facilitation of information to assist with return to work efforts.
Negotiate appropriate treatment plans with medical providers.
May assist the Claims Examiner with authorization requests utilizing medical records and Montana Utilization and Treatment Guidelines.
The MCM may be called upon to attend strategic staffings, large loss, litigation, mediation, DOM care or large purchase meetings.
The MCM may be required to make presentations to claims examiners, other nurses or at All Employee meetings.
Required: Current RN licensure with four (4) years clinical experience.
Bachelor of Science in Nursing (BSN)
Case management experience in workers’ compensation
Certifications listed below:
Certified Case Manager
Certified Rehabilitation Registered Nurse
Certified Occupational Health Nurse
Certification in Case Management
Certified Managed Care Nurse
Home Health or Medical-Surgical Nursing
Employer will assist with relocation costs.
Internal Number: 30074
About Montana State Fund
Montana State Fund is an independent public corporation headquartered in Helena, Montana. Our ever-changing work environment is fast-paced and high-energy. Since 1990, we have worked with governors and legislatures to build a viable and competitive workers' compensation system, improving operational efficiency and allowing for employers to have the most flexibility to obtain coverage at competitive prices. Over the years, we have evolved from a traditional organizational structure to one that is adapted to the needs of the information age. It's a system that has worked for Montana - and for the many people we employ.
Montana State Fund works hard to retain great talent by offering a comprehensive benefit package, and then some. In fact, benefits include higher education reimbursement, plus training and development programs. What's more, you can set up special medical expense accounts for tax-free income, much like a flex plan.
Competitive salary and benefits are only half the story. The other half is about you and your decision to live and work in Montana. At Montana State Fund, you'll find that our people appreciate their surroundings. They live a balanced life, by worki...ng hard and enjoying their beautiful home state. It shows in the quality of their work - and the smiles on their faces.