Role Description We are excited to announce an opportunity to join our medical strategy team as a Nurse Case Manager. This full-time, exempt position offers the flexibility of working remotely while contributing to a high-impact, growing team. Position Overview: - Responsible to provide case management coordination for claimants with compensable injuries. - Participate collaboratively with various members of claims team, treatment providers and network vendors. Responsibilities/Essential Functions: - Negotiates fees with vocational rehabilitation, medical case management and DME vendors. - Coordinates and monitors referrals to rehabilitation and medical case management vendors. - Coordinates services as indicated with HIG Utilization Review department nursing staff. - Gathers, compiles, analyzes and reports service data significant to clients. - Acts as resource to claims professionals, underwriting and account representatives for identification of appropriate medical services, goods and providers. - Coordinates MDL requirements for ongoing certification. - Reviews and determines need for an Independent Medical Exam, including area of medical specialty. - Assists in projection of reserves for the life of the claim and collaborates with adjuster for Roundtables. - Assesses healthcare needs associated with compensable/covered illness/injury claims and comorbidities. - Coordinates and arranges for cost effective service delivery that is consistent with the claimant's health care requirements and policy benefits. - Educates and evaluates injured/ill claimant/class member, insured party, and health care provider regarding patient's response to treatment to enhance claimant adherence and progress toward maximum medical improvement as well as Return to Work planning. - Monitors and evaluates claimants' responses to medical treatment and progress in recovery, and makes recommendations for alternative treatment or care options if needed. - Collaborates with treatment providers and claimant for cost effective medical treatment. - Assists with removing roadblocks to treatment adherence by the claimant or insured party. - Coordinates and monitors clinical treatment services such as discharge planning, medical specialty referrals, and vendor needs. - Evaluates the components of the injured/ill claimant's job with claimant and employer and, if appropriate, clarifies the critical demands of the job and suggests any necessary modifications or accommodations to comply with government regulations (in WC/PIP claims) with a focus on ability and return to work. - Reports electronic data for utilization of NCM resources and claimant progress and outcomes with HIG guidelines and software programs. - May assist/direct clients in applying for social security disability. - Participate and prepare educational presentations to nursing peers and claims department staff as needed. Qualifications - Registered nurse with current state licensure. - Certified Case Manager certification preferred. - Minimum of three years of clinical experience in applicable nursing specialty field (i.e. occupational health, rehabilitation, orthopedics, home care, emergency, etc.). - Working knowledge of utilization review process, medical bill review and/or medical case management. - Ability to collaborate and work effectively in a team environment. - Strong analytical, problem solving and negotiation skills. - Effective interpersonal communication and writing skills. - Organization skills with regard to time management, task prioritization, and integration of information from a variety of sources. - Ability to determine and meet internal and external customer needs. - Word processing skills. - Fluent in English. - Knowledge of technical materials, rules, procedures or facts required to effectively performing the role such as: utilization criteria (Intermural), medical coding mechanisms (ICD-9 CM, CPT-4, DSM-IV), case management standards of practice, state workers' compensation and personal injury protection (PIP) regulations. - Ability to adapt to a dynamic work environment. - PC/Keyboard skills. Requirements - Ability to use a personal computer and other standard office equipment. - Ability to travel as necessary. - Ability to sit and/or stand for extended periods. Benefits - Medical, dental, vision, life, and disability insurance. - 401K with a company match. - Tuition reimbursement. - PTO. - Company paid holidays. - Flexible work arrangements. - Cultural Awareness Day in support of IDE. - On-site medical/wellness center (Worcester only).

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