The Medical Case Manager coordinates resources and creates flexible, cost-effective options for ill or injured individuals on a case-by-case basis to facilitate quality individualized treatment goals, including timely return-to-work if appropriate. The Medical Case Manager will rely on their medical knowledge to evaluate the patient’s current treatment plan for medical appropriateness based on their physical and medical status. The Medical Case Manager must be able to discuss the patient’s medical and physical conditions with the treating physicians, along with discussing/ recommending alternate treatment plans for the patient.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:
Provides medical case management to individuals through communications with the patient, the physician, other health care providers, the employer and the referral source.
Makes recommendations regarding health care resources.
Develops Independent Medical Evaluation Plans. Provides assessment, planning, implementation and evaluation of patient’s progress.
Evaluates patient’s treatment plan for appropriateness, medical necessity, and cost effectiveness.
Implements care such as negotiation the delivery of durable medical equipment and nursing services. Devises cost-effective strategies for medical care.
Attends doctors, other providers, and attorney’s visits. Attends hospital and/or long-term facility discharge planning conferences, et cetera for the purpose of determining appropriateness of care and developing an effective long-term care strategy. Initial home visit for initial evaluation.
Assesses rehabilitation facilities for appropriateness.
Utilizes their medical and nursing knowledge to discuss the current treatment plan with the physician and discuss alternate treatment plans.
Performs or manages architectural assessment of patient’s home.
Researches medical and community resources for medical and community resources for patients with catastrophic or chronic diagnoses, such as but not limited to, AIDS, cancer, spinal cord injury, diabetes, head injury, back injury, hand injury, burns, et cetera.
Associates Degree in Nursing required, BSN desirable.
Graduate of accredited school of nursing
Current RN Licensure in state of operation
Valid driver’s license and good driving record with no traffic violations
3 or more years’ of recent clinical experience, preferably in rehabilitation.
URAC recognized Case Management certification (ACM, CCM, CDMS, CMAC, CMC, CRC, CRRN, COHN, COHN-S, RN-BC) required to be obtained within 3 years of hire if no nationally recognized certification is present at time of hire.
Strong clinical background in orthopedics, neurology, or rehabilitation preferred.
Strong cost containment background, such as utilization review or managed care helpful.
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