Complex Care Nurse Case Manager
Location
EST (UTC-5)
Posted
19 hours ago
Salary
$75K - $115K / year
Seniority
Lead
No structured requirement data.
Job Description
Complex Care Nurse Case Manager
MEDI TRANS LLC
Role Description The Complex Care Nurse Case Manager provides clinical oversight and medical-necessity support for complex workers’ compensation claims across MTI America’s ancillary service lines. This role reviews clinical information, collaborates with internal teams and external stakeholders, and helps ensure timely, appropriate, and cost-conscious care recommendations for injured workers. The ideal candidate brings strong clinical judgment, critical thinking, communication, and relationship-building skills. This position is well suited for an RN who can apply clinical experience in a non-direct-care environment, manage multiple priorities, and adapt to a specialized workers’ compensation and ancillary-services setting. Key Responsibilities - Provide clinical oversight and support for complex claims involving Home Health, Physical Medicine, Transportation, Language Services, Medical Care, Durable Medical Equipment, orthotics and prosthetics, respiratory equipment and supplies, medical supplies, and home or vehicle modifications. - Review medical records, physician orders, progress notes, claims information, and clinical documentation to assess medical necessity and appropriateness of requested services. - Apply clinical judgment, established medical criteria, and applicable state jurisdictional requirements when making medical-necessity recommendations. - Analyze inpatient level-of-care documentation and assist with clinical review of proposed, concurrent, or retrospective services. - Review CPT and HCPCS coding, charges, and potential up-coding concerns as part of claims and service review. - Audit medical-necessity claims, peer-review reports, correspondence, addendums, and supplemental reviews in accordance with departmental policies and procedures. - Obtain and organize clinical information needed to support authorization recommendations for nurse case managers, adjusters, and internal stakeholders. - Provide direct clinical oversight and management of Complex Care Acute, Complex Care, and Complex Care Specialty claims within the MTI 360 platform. - Partner with coordinators to monitor complex cases and provide periodic patient-status updates. - Serve as a key clinical liaison between Claims, Medical Services, Operations, clients, nurse case managers, providers, and other stakeholders. - Build and maintain collaborative relationships with physicians, nurses, nurse case managers, ancillary providers, adjusters, and clients. - Support client satisfaction through timely communication, thoughtful discharge-planning support, responsiveness, and clinically appropriate recommendations. - Support the Sales team as a clinical and complex-care subject-matter expert during client meetings, stewardship discussions, and prospective-client opportunities. - Create and deliver educational programs, including CEU content, for insurance carriers, TPAs, nurse case managers, adjusters, and other external audiences as needed. - Assist with the development and implementation of utilization-management and clinical-review programs, including the use of ODG guidelines where applicable. - Participate in business meetings, conferences, webinars, and other professional-development or client-facing activities as needed. - Learn and effectively use MTI systems, workflows, and documentation processes through onboarding and ongoing training. Qualifications - Active, unrestricted Registered Nurse (RN) license. - Bachelor’s Degree in Nursing. - Three to five years of nursing experience in a hospital, clinical, managed-care, utilization-review, case-management, or comparable healthcare setting. - Strong knowledge of medical terminology, diagnoses, clinical documentation, and physician orders. - Experience reviewing medical records, progress notes, and clinical information to support care decisions. - Demonstrated critical-thinking, clinical-judgment, problem-solving, and decision-making skills. - Strong written and verbal communication skills, including the ability to communicate clinical information clearly to both clinical and non-clinical audiences. - Ability to build effective working relationships with internal teams, clients, providers, nurse case managers, and other stakeholders. - Strong organizational skills and ability to manage multiple files, priorities, and turnaround-time expectations. - Ability to work independently in a remote environment while remaining responsive and collaborative. - Comfort learning new systems, processes, and a specialized workers’ compensation environment. - Proficiency with Microsoft Office, including Word, Excel, and Outlook. - Ability to comply with company policies, HIPAA requirements, and applicable state and federal regulations. Preferred Qualifications - Certified Case Manager (CCM) credential or progress toward certification. - Workers’ compensation experience. - Experience supporting ancillary services, including Home Health, Durable Medical Equipment, home or vehicle modifications, respiratory equipment, orthotics and prosthetics, or related services. - Utilization-review, utilization-management, or formal case-management experience. - Active bedside or direct-patient-care nursing experience. - Experience with discharge planning, care coordination, inpatient review, or complex-care management. - Experience auditing claims, clinical documentation, medical-necessity determinations, or coding-related concerns. - Experience presenting, participating in webinars, or delivering clinical education to external audiences. - Experience working with ODG guidelines or similar evidence-based clinical-review criteria. Core Competencies - Clinical judgment and critical thinking - Problem solving and sound decision-making - Written and verbal communication - Relationship building and stakeholder management - Responsiveness and follow-through - Organization and file management - Adaptability and willingness to learn - Client-service mindset - Ability to work effectively in a specialized, non-emergent clinical environment Schedule & Availability - Core business hours are generally 8:00 a.m. to 5:00 p.m. Eastern Time, with flexibility based on business needs. - This role is not routinely on call; however, occasional after-hours availability may be needed to support urgent business or client needs. - This position involves regular communication by phone, email, and virtual meetings. - Approximately 25% to 30% of the role may involve phone-based communication with clients, providers, nurse case managers, adjusters, and internal partners. Work Environment & Physical Requirements - Remote office environment. - May require occasional travel for client meetings, conferences, or business needs. - Ability to sit or stand for extended periods. - Ability to communicate effectively by phone, video conference, email, and other virtual communication tools. - Ability to lift up to 5 pounds, if applicable. Compensation & Benefits - Competitive salary based on experience. - Health, dental, and vision insurance. - 401(k) with company match. - Paid time off and holidays. Equal Opportunity Employer MTI America is proud to be an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.
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