Risico Total Managed Care, Inc.
Medical Management Nurse
Risico Total Managed Care, Inc. (Risico) is seeking a qualified Medical Management Nurse to join the Risico Team in our Fresno office. We are very excited about the growth of our company and new areas of expansion. We are willing to train candidates in workers comp if they have the right qualifications and background.
Qualifications, Education, Skills, Experience and Attendance 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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
● Graduate of accredited Registered Nursing Program. Current unrestricted California RN license.
● BSN desirable.
● Strong clinical background in orthopedics, emergency room, intensive care, neurology, occupational medicine or rehabilitation useful. Strong cost containment background, such as utilization review or managed care also useful.
● One to two plus years of recent clinical experience and/or one to two years of recent managed care experience.
● Bilingual Spanish Speaking skills desirable.
● Achieves URAC- recognized certification in case management with four (4) years of hire
We offer a competitive salary, excellent opportunities for growth and a comprehensive benefit package. Benefits are listed below;
● Medical Coverage
● Dental Reimbursement
● 401 (k) with Employer Match
● Holiday Pay
● Vacation/ Sick Pay
● Paid “flex” day per month
● Paid Birthday off
● Relaxed Dress Code
● Health Spending Account
● Employee and Dependent life insurance
● Disability Insurance
● Section 125 – FSA
● Appointment Time ( non-exempt staff)
● Additional Optional Insurance
Role and Responsibilities:
These duties include but are not limited to;
● Conducts prospective, expedited, concurrent and retrospective reviews related to medical treatment requests for authorization
● On assigned case management cases, assesses severity of the injury, evaluates treatment plans and the extent of disability, and collaborates with all applicable parties in order to establish goals that facilitate a safe/timely return to work as well as to achieve maximum functional restoration for the injured worker.
● Ensure the privacy and security of Protected Health Information (PHI).
● Consistent and effective communication with injured workers, medical professionals, administrative assistants, claims staff, employers and all stake holders is a primary responsibility
● Responds to various written and telephone inquiries in a timely manner regarding the status of the case.
● Engages in the proper use of resources including the TMC Medical Director, Peer Review, various vendors and other applicable resources to achieve optimal outcomes on each case
● Consistently maintains confidentiality on any/all cases, professional, positive and appropriate communications, accurate documentation including goals, interventions, recommendations and decisions regarding assigned case management cases.
● Prioritizes and coordinates multiple responsibilities while working closely with internal and external customers.
● Document the use/source of evidence based guidelines utilized when performing a clinical review regarding requests for medical treatment authorization.
● Forwards to the Medical Director or clinical peer reviewer’s cases which do not meet initial clinical criteria in the performance of utilization review. Medical Management Nurses do not issue denials.
● Document the use of best practice references such as standardized disability duration guidelines and medical management resources /references utilized while performing case management assessments, activities and interventions.
● Functions as a clinical resource to administrative assistants, claims staff, employers and injured workers.
● Reports any actual or potential quality issues or potential serious medical treatment concern issues to the VP/Director of Nursing, Utilization Review/ Medical Management Nurse Supervisor and/or Medical Director.
● Limited local travel may be required for occasional field/site visits.
● Maintains billable hours appropriate to role and assigned accounts.
● Must be able to work at least 40 hours per week, Monday thru Friday and be available to work extended hours as situations arise.
● Negotiation skills are necessary to establish and facilitate treatment.
● Perform other related duties as required.
Maintain confidentiality, professional, positive and appropriate communications, accurate documentation including goals, interventions, recommendations and decisions regarding each case. Prioritize and coordinate multiple responsibilities while working closely with internal and external customers.