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Claims Case Manager, RN

Category: Classified/Excluded
Pay Grade: C31
Job Code: 15890

To perform this job successfully, an individual must be able to perform the essential job functions satisfactorily.  Reasonable accommodations may be made to enable individuals with disabilities to perform the primary job functions herein described.  Since every duty associated with this position may not be described herein, employees may be required to perform duties not specifically spelled out in the job description, but which may be reasonably considered to be incidental in the performing of their duties just as though they were actually written out in this job description.

JOB SUMMARY

This is professional case management work performed by a licensed registered nurse managing State of Florida Workers Compensation and bodily injury program processes on behalf of Pinellas County Government. The incumbent ensures effective delivery of comprehensive workers compensation medical claims management services and support. Tasks and assignments require the incumbent to complete extensive telephone, personal computer systems tracking and field case management on behalf of Pinellas County Government. The incumbent provides initial and ongoing clinical assessments for on the job injury case management and maintains regular contact with physicians, other medical providers, injured employees, and supervisors. The incumbent defines strategies on medical management and completes professional assessments used to manage medical and disability exposure and return to work opportunities. Substantial time is required performing Pinellas County’s workforce case management via telephonic and computer contacts with parties although some work occurs at worker field locations. The incumbent works extensively to manage Florida workers compensation injuries which include telephonic and field work with a strong understanding of the Heart/Lung Bill applicable to law enforcement personnel. The incumbent will also be required to complete case assessments for worker’s compensation and bodily injury claims asserted by third parties. The incumbent must apply advanced professional nursing principles and techniques to a wide variety of patient care problems and situations. The incumbent completes professional nursing assignments and makes nursing decisions independently without any direct professional supervision; however, the position does report administratively to a senior manager or designee.

ESSENTIAL JOB FUNCTIONS (examples, not all inclusive)

• Performs initial and ongoing clinical assessment via telephone calls to injured employees, supervisors, physicians and attorneys as indicated, and assessment of employee’s situation will include psychosocial needs, cultural implications and support systems in place;
• Creates a case management plan based on the assessment with measurable goals and objectives utilizing evidence-based criteria, monitoring ongoing progress toward these goals and objectives; implements plan through case management interventions and communication with all parties to reach desired goals and objectives;
• Schedules appointments with outside doctors, hospitals, clinics, labs, and radiology facilities;
• Coordinates, schedules, negotiates, and coordinates prompt return-to-work plans with parties;
• Accompanies injured employees to medical appointments when needed for purposes of education for employees and attaining appropriate work restrictions;
• Maintains client privacy and confidentiality; promotes safety; and adheres to ethical, legal, accreditation and regulatory standards;
• Provides information and guidance to individuals;
• Maintains accurate, detailed reports, and records;
• Records patients’ medical information and workers compensation information;
• Monitors, records, and reports changes in patients’ conditions;
• Consults with healthcare team members to assess, plan, implement or evaluate patient care plans;
• Modifies patient treatment plans as indicated by authorized physicians;
• Instructs individuals or other groups on topics such as health education and disease prevention, and develops health improvement programs;
• Prepares and delivers various training to individuals and groups;
• Performs other related job duties as assigned.

QUALIFICATIONS

Education and Experience:

High School diploma or an acceptable equivalency diploma (GED);

Candidate must be a graduate from an accredited professional registered nurse program with a State of Florida Registered Nurse (RN) license AND possess: three (3) years of professional employment performing advanced level workers compensation case management experience implementing the full range of initial, ongoing, and final resolutions on workers compensation cases with preference given to candidates possessing or in the process of obtaining one or more designations (CCM, CDMS, CCRN or COHN) detailed below; or 

Five (5) years of experience as a professional clinical nurse with a preference for previous insurance nurse case management, orthopedic, emergency room, critical care, home care or rehabilitation care; or

1 or more occupation related certifications or designations: (CCM, CDMS, CCRN or COHN); or an equivalent combination of education, training and/or experience.  

Special Qualifications (May be required depending on area of assignment):

• Florida Driver’s License or Florida Commercial Driver’s License and endorsement, if any.
• Assignment to work a variety of work schedules including compulsory work periods in special, emergency, and/or disaster situations.
• Preference may be given and the appointee may be required to obtain one or more designations, such as:  (Certified Case Manager (CCM); Certified Disability Management Specialist (CDMS): Certified Critical Care Nurse (CCRN); Certified Occupational Health Nurse (COHN).
• Other highly desirable knowledge, skills, abilities, and credentials required for a specific position.

Knowledge, Skills and Abilities:

• Knowledge of the State of Florida workers compensation laws and regulations at an advanced level, including the Heart/Lung bill;
• Knowledge of the information and techniques needed to diagnose and treat human injuries, diseases, and deformities; This includes symptoms, treatment alternatives, drug properties and interactions, and preventive health-care measures;
• Knowledge of principles, methods, and procedures for diagnosis, treatment, and rehabilitation of physical and mental dysfunctions, and for career counseling and guidance;
• Knowledge of principles and processes for providing customer and personal services; This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction with ability to establish and maintain effective working and professional relationships with employees, co-workers, physicians, and superiors;
• Skill in negotiations;
• Skill in oral and written communication in health, medical, and administrative matters including presentation skills;
• Ability to work in a team environment;
• Ability to operate a personal computer and other automated systems to enter and retrieve information, monitor work performed and to communicate information in reports, etc.;
• Ability to evaluate needs and courses of action for alternative treatments;
• Ability to apply standard nursing knowledge and techniques to a wide variety of patient care situations;
• Ability to apply computer applications and software;
• Ability to analyze and persuade others to take action applying positive interpersonal skills;
• Ability to manage workflow and make independent decisions.

PHYSICAL/MENTAL DEMANDS

The work is light work which requires exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force to move objects.  Additionally, the following physical abilities are required:

• Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.
• Hearing: Perceiving the nature of sounds at normal speaking levels with or without correction. Ability to receive detailed information through oral communication, and to make the discrimination in sound.
• Mental acuity: Ability to make rational decisions through sound logic and deductive processes.
• Speaking: Expressing or exchanging ideas by means of the spoken word including the ability to convey detailed or important spoken instructions to other workers accurately and concisely.
• Standing: Particularly for sustained periods of time.
• Talking: Expressing or exchanging ideas by means of the spoken word including those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.
• Visual acuity: Have close visual acuity such as color differentiation, depth perception, and adequate field vision.
• Walking: Moving about on foot to accomplish tasks, particularly for long distances or moving from one work site to another.

WORKING CONDITIONS

Work is sometimes performed in an environment in which personal errors may lead to significant physical or mental consequences for the incumbent and co-workers.