Manager Nurse Case Management AF Group
AF Group

Kalamazoo, Michigan

This job has expired.


SUMMARY:

Responsible for the management and oversight of the nurse case management team and the analysis of Nurse Case Manager (NCM) caseloads for varying medical management activities. Work collaboratively with claims managers and Corporate Claims team in developing, implementing and statistically tracking results for medical management strategic initiatives.

RESPONSIBILITIES/TASKS:

  • Align with department claims handling philosophy and leads team in support of department initiatives and strategies in cost containment, medical management, customer service, training and quality, etc.
  • Complete monthly NCM audit reviews and review results with NCMs and Director.
  • Develop monthly metric tracking tools for assessing results of medical management programs performed by NCM.
  • Complete monthly metric analysis of NCM caseloads, new claim assignment and medical management initiatives.
  • Attend claims meetings to assess NCM involvement, effectiveness and develop plans to address medical cost drivers per state.
  • Analysis monthly field case management (FCM) spend, utilization and claim FCM thresholds.
  • Oversight of all FCM vendors assessing monthly/quarterly spend, quality of service and in developing case management protocols.
  • Develop medical protocols for medical procedures that require NCM assessment.
  • Develop medical education programs for NCM and claims team.
  • Works with Corporate Claims in identifying and developing new medical management initiatives.
  • Works with NCM team regarding utilization of evidenced based medical guidelines.
  • Assess outside vendors services that provide additional medical cost containment.

Supervisory: Supervisory: Directly manages exempt staff. Carries out responsibilities in accordance with company policies and applicable laws. Responsibilities include interviewing, selecting and training employees, planning, assigning and directing work, appraising performance, rewarding and disciplining employees, addressing complaints and resolving problems.

This position description identifies the responsibilities and tasks typically associated with the performance of the job. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS

EDUCATION OR EQUIVALENT EXPERIENCE:

Bachelor's degree in Nursing or related field. Valid state nursing license preferred. Combinations of relevant education and experience may be considered. Continuous learning required, as defined by the Company's learning philosophy. Certification (i.e. CCM, CRRN, COHN, CDMS and/or RNC) or progress toward certification is highly preferred and encouraged.

EXPERIENCE:

Five years experience of progressive responsibility in a claims environment with demonstrated technical knowledge with relevant skills, knowledge and abilities required. A minimum of three years of demonstrated leadership in claims required. Workers' compensation and occupational health insurance experience preferred.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
  • Demonstrated leadership abilities.
  • Extensive knowledge and understanding of related legal and regulatory requirements including but not limited to FMLA. For providing NCM services within multiple jurisdictions
  • Knowledge of ODG and/or ACOEM guidelines.
  • Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization exists.
  • Excellent verbal and written communication skills required.
  • Ability to utilize software applications in creating statistical report and metric for monitoring and assessing the effectiveness of the NCMs and the program results.
  • Ability and proficiency in the use of computers and company standard software specific to position.
  • Ability to effectively present and exchange information clearly and concisely, present ideas, report facts and other information and respond to questions as appropriate.
  • Ability to negotiate complex disputes while establishing and maintaining effective working and client relationships.
  • Ability to analyze utilization data and resolve conflicts pertaining to claims.
  • The ability to work independently and with other managers in resolving identified deficiencies or problems.
  • Knowledge of Standards and Practice for case managers.

WORKING CONDITIONS:

Work is performed in an office setting with no unusual hazards. Minimal travel.

The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.

We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.


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