Catastrophic Telephonic Nurse Case Manager

About the role

Manage claims involving severe traumatic injuries, spinal cord injuries, traumatic brain injuries, amputations, severe burns, polytrauma, and other catastrophic conditions.

Monitors, coordinates, and evaluates complex and catastrophic workers' compensation claims to ensure appropriate, effective, and cost-efficient medical care.

Identify current and anticipated medical needs, including hospitalization, rehabilitation, durable medical equipment (DME), home health services, attendant care, and specialty treatment.

Coordinates medical services with physicians, specialists, rehabilitation providers, hospitals, home health agencies, and ancillary vendors to facilitate continuity of care.

Identifies barriers to recovery, treatment compliance, and return-to-work progression and develops appropriate action plans to address them.

Serves as a clinical resource to claims professionals, employers, providers, injured workers, and other stakeholders by providing recommendations regarding medical treatment, prognosis, and disability management.

Maintains accurate and timely documentation, clinical summaries, recommendations, and claim notes while ensuring compliance with workers' compensation regulations, nursing standards, and company policies.

Evaluates requests for field case management and other specialized medical management services.

Performs other duties as assigned.

Responsibilities

• Manage claims involving severe traumatic injuries, spinal cord injuries, traumatic brain injuries, amputations, severe burns, polytrauma, and other catastrophic conditions.
• Monitor, coordinate, and evaluate complex and catastrophic workers' compensation claims to ensure appropriate, effective, and cost-efficient medical care.
• Identify current and anticipated medical needs, including hospitalization, rehabilitation, durable medical equipment (DME), home health services, attendant care, and specialty treatment.
• Coordinate medical services with physicians, specialists, rehabilitation providers, hospitals, home health agencies, and ancillary vendors to facilitate continuity of care.
• Identify barriers to recovery, treatment compliance, and return-to-work progression and develop appropriate action plans to address them.
• Serve as a clinical resource to claims professionals, employers, providers, injured workers, and other stakeholders by providing recommendations regarding medical treatment, prognosis, and disability management.
• Maintain accurate and timely documentation, clinical summaries, recommendations, and claim notes while ensuring compliance with workers' compensation regulations, nursing standards, and company policies.
• Evaluate requests for field case management and other specialized medical management services.
• Perform other duties as assigned.

Requirements

• Education: Associate Degree in Nursing required. Bachelor of Science in Nursing (BSN) preferred.
• Current unrestricted Registered Nurse (RN) license required; Compact RN licensure preferred.
• Experience: Minimum of 5 years of direct clinical nursing experience required, preferably in acute care, trauma, critical care, rehabilitation, or a related specialty. Preferred 3-5 years of catastrophic workers' compensation case management experience with a demonstrated ability to manage complex, high-exposure claims from initial referral through claim resolution. Experience navigating workers' compensation regulations, medical management practices, treatment guidelines, utilization review processes, and return-to-work programs across multiple state jurisdictions is strongly preferred.

Qualifications

• Extensive knowledge of workers' compensation medical management principles, evidence-based treatment guidelines, and disability management practices.
• Strong ability to assess complex medical conditions, analyze medical records, identify barriers to recovery, and develop effective case management strategies.
• Excellent organizational, written, verbal, and interpersonal communication skills.
• Ability to collaborate with multidisciplinary teams and manage multiple priorities while maintaining confidentiality.
• Demonstrated proficiency with claims management systems, electronic medical records, and Microsoft Office applications.
• Viewed as a clinical resource for complex and catastrophic claims management.

Work Arrangement

This position may be structured as either a hybrid or fully remote role. Hybrid work arrangements are available for internal and external candidates. A fully remote work arrangement may be considered for highly qualified external candidates who demonstrate extensive experience in catastrophic workers' compensation case management, proven success managing complex claims independently, and the ability to effectively collaborate and achieve outcomes in a remote work environment.

Benefits

• We offer competitive benefits packages for full-time and part-time employees.
• Full-time employees have access to medical, dental, and vision coverage, wellness plans, parental leave, adoption assistance, and tuition reimbursement.
• Full-time and eligible part-time employees also enjoy Paid Time Off and paid holidays, a 401(k) plan with company match, an employee stock purchase plan, and commuter benefits.
• Compensation varies by role, level, and location and is influenced by skills, experience, and business needs.
• Your recruiter will provide details about benefits and specific compensation ranges during the hiring process.

Contact

Learn more at http://www.gaig.com/careers.