Nurse Case Manager
MorningStar Health has retained Management Business Solutions (MBS) as a collaborative partner to manage the applicant screening process. We have aligned our recruiting processes to identify, attract and screen candidates.
General Summary:
The role of the Nurse Case Manager (NCM) is to medically manage and process claims; to determine benefits due pursuant to a short term disability plan and to ensure the ongoing processing of claims. To analyze reported Family Medical Leave (FMLA) requests; to make determinations based on state and federal regulations; to communicate clearly with clients and claimants on all aspects of claims process; to ensure that on-going claim management is within company service standards and industry best practices; and to act as the company liaison with clients in regards to disability management software issues.
Education:
- RN, NP, or PA license (State of Michigan). CCM certification preferred. CME maintenance to support licensure.
Experience/Credentials/Certifications:
- 5+ years’ experience as an RN, NP, or PA. 2+ years’ experience of case management experience. Must be credentialed by MorningStar Health.
Duties:
- Medically manages disability claims ensuring compliance with duration control guidelines and plan provisions
- Analyzes, approves and authorizes assigned STD claims and determines benefits according to the client STD Plan Document and Best Practice Benchmark Guidelines.
- Analyzes and process FMLA claims to determine eligibility, certification and claims designation are in compliance with state and federal regulations. Communicates decisions and on-going expectations with claimants and clients.
- Communicates clearly with claimant and client on all aspects of claims process either by phone and/or written correspondence
- Obtain and review background medical and behavioral healthcare documentation relating to all cases as described in the various MSH policies and procedures. Updates the patient’s case in PRS in within two business days of activity. Ensure that all transfers of medical, behavioral and complementary health records are done in a manner that is confidential and HIPAA compliant.
- Provide care management after a patient’s return to work; helping ensure effective and timely implementation of a MSH treatment plan, work closely, professionally and frequently with the patient, the treating physician, the health care provider (PCP), and other medical, behavioral and complementary healthcare providers, tracks and submits time involvement monthly.
- Coordinate quarterly wellness bio-metric and health coaching services for client companies.
- Provide Comprehensive Health Care Assessments (CHA) for client companies.
- Participates in department meetings and other administrative duties as directed by supervisor.
- Displays professional courtesy at all times.
- Analytical and interpretive skills.
- Strong Organizational skills.
- Excellent oral and written communication skills
- Knowledge of medical disability management
- Knowledge of state and federal FMLA regulations.
- Maintains regular and predictable attendance.
- Performs other duties and responsibilities as assigned.
Physical Requirements/Working Conditions:
While performing the duties of this job, this position requires clear and conceptual thinking ability; excellent judgment and problem solving analysis, and the ability handle multiple priorities simultaneously. This position also requires the ability to be independently mobile, sit, stand, use extremities and fingers, talk, hear, and smell. May occasionally lift up to10 pounds.
Must have vision abilities including close vision, distance vision, color vision, peripheral vision, and depth perception.
Must have a valid, non-restricted, Michigan Driver’s license.
