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Medical Case Manager II

CLAIM YOUR FUTURE AS A GREAT PERFORMER!

Continuing double-digit revenue growth rates and progressive employment practices make Sedgwick Claims Management Services the place where great people can do great things for clients while maximizing their career possibilities. We have earned a reputation for innovation, quality, sustained growth, financial stability and a colleague-friendly work environment. We are proud to have been voted the Best TPA in America for 2005 and 2006, and the first and only Third Party Administrator to receive the coveted Employer of Choice designation. Come be a part of our team and "Claim Your Future."

PRIMARY PURPOSE:
To analyze claims based on complexity, technical difficulty and/or medical management issues; to adjust disability claims; and to evaluate and arrange appropriate referral of claims to outside vendors.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES
Analyzes claims based on complexity, technical difficulty and/or medical management issues.
Adjusts disability claims requiring medical management intervention and/or medical management.
Informs claimants of documentation required to process claim and timeframes if any.
Manages claim to ensure compliance with duration control guidelines.
Coordinates investigative efforts to ensure appropriateness and provide thorough review of complex, contested claims.
Evaluates and arranges appropriate referral of claims to outside vendors for medical case management, surveillance, and independent medical evaluation.
Approves and authorizes disability claims pursuant to a disability plan.
Determines benefits due and calculates and monitors reserves for each claim.
Maintains professional client relationships.
Communicates status on decisions to client, claimant and supervisor.
Maintains a quality assurance program to support the total performance management initiative and the consistent delivery of quality claims service.

QUALIFICATIONS

Education & Licensing
Baccalaureate degree in nursing (BSN) from an accredited college or university or equivalent work experience preferred. Active RN license or Certification in Social Work (LCSW) required. Certification in rehabilitation nursing or a related specialty is highly preferred. Valid driver's license required.

Experience
Three (3) years of clinical experience required.

Skills & Knowledge
Knowledge of workers compensation laws and regulations
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Leadership/management/motivational skills
Analytical and interpretive skills
Strong organizational skills
Excellent interpersonal skills
Excellent negotiation skills
Ability to work in a team environment
Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT
When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

Sedgwick CMS is an Equal Opportunity Employer
and a
Drug-Free Workplace

How to apply: DO NOT use the Apply Online button. Please copy and paste the following link into your browser address bar:
http://sedgwickcms.contacthr.com/20773108

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Published on Aug 05, 2011
Viewed: 244 times