Job Description

POSITION SUMMARY:

Responsible for assessing, planning, implementing, and coordinating worker’s compensation nurse case management activities. To evaluate the medical and disability needs of an injured worker and facilitate the appropriate and timely medical care and return to work. Act as a liaison with the injured worker, claims adjuster, providers, and healthcare personnel. This role integrates clinical expertise, utilization management standards, and claims data analysis to forecast anticipated medical care and costs, support negotiations, inform reserves, and improve quality and outcomes.

KEY RESPONSIBILITIES AND ESSENTIAL FUNCTIONS:

• Conduct comprehensive clinical assessments, develop medical cost projections and/or summaries for Medicare set asides.
• Provide telephonic and field-based nurse case management when appropriate, engaging injured workers, families, providers, and payers to remove barriers, improve treatment adherence, and optimize clinical outcomes.
• Ensure injured workers receive timely, evidence-based medical care that supports their treatment plan and recovery goals.
• Serve as a trusted clinical resource to claims teams by actively participating in file reviews and delivering expert analysis and actionable insights on medical status, treatment plans, and anticipated care needs—supporting accurate reserving, cost projections, and strategic claims decisions.
• Perform additional duties and assignments as required to support organizational goals and compliance standards.

MINIMUM QUALIFICATIONS:

• Active Registered Nurse (RN) license in applicable state(s); multistate compact license preferred.
• 3–5+ years of clinical case management experience in payer, provider, workers’ compensation, complex care, or catastrophic case management.
• Demonstrated experience developing medical cost projections or performing cost-of-care analyses (e.g., reserves, settlements, vendor proposals).
• Working knowledge of reimbursement methodologies (DRG, OPPS, RBRVS, case rates, fee schedules), ICD-10/CPT coding, and medical necessity criteria.
• Strong analytical and communication skills—able to translate clinical plans into financial models and present findings to clinical and non-clinical stakeholders.
• Compliance mindset with HIPAA and URAC/NCQA-aligned case management practices.

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