GENERAL DESCRIPTION:

The Department of Workforce Services is seeking a Nurse Case Manager to coordinate, evaluate, and monitor medical care services being provided to injured workers receiving benefits under the Workers' Compensation system; provide assistance to health care providers, employers, and division professionals in coordinating care and treatment plans to return injured workers to a pre-injury status and return to work.

Human Resource Contact: 307-777-8727

ESSENTIAL FUNCTIONS: The listed functions are illustrative only and are not intended to describe every function which may be performed at the job level.

Evaluate claimant needs and medical records to direct medical case management activities.
Provide assistance to healthcare providers, employers, and division professionals in coordinating care and treatment plans.
Ensure that appropriate medical care is delivered to injured workers in a manner that is consistent with the statutes, rules, and regulations of the division.
Perform a medical review screening on pre-authorization requests for proposed surgical procedures.
Obtain all medical documentation to accompany the pre-authorization requests.
Refer cases for peer review as indicated from treatment guidelines and medical reviews.
Document all interactions, reviews, approvals, and denials in the claims management system.
Review CPT and ICD-10 codes, and surgical descriptions for accuracy on pre-authorization requests.
Review medical documentation utilizing the Division's treatment guidelines for surgical procedures.
Maintain tracking of all pre-authorization referrals, surgical procedures, clinical bills, and prescription requests
Review pre-authorization provider requests for compliance with treatment guidelines.
Act as a medical resource for claims analysts; write medical questions for multi-types of evaluations.
Review medical bills, prescription requests, UDS, chiro/PT treatments, and DME for relatedness.

KNOWLEDGE:

Knowledge of community resources.
Skills in counseling and consultation.
Ability to apply principles of nursing, particularly medical terminology, and physical and psychosocial principles.
Ability to interpret diagnostic testing.
Ability to critically analyze data.

MINIMUM QUALIFICATIONS:

Education:

Bachelor's Degree (typically in Nursing)

Experience:

1-2 years of progressive work experience (typically in Nursing)

Certificates, Licenses, Registrations:
Must be licensed or eligible for licensure as a Registered Nurse (RN) in the State of Wyoming

OR

Education & Experience Substitution:

4-6 years of progressive work experience (typically in Nursing)

Certificates, Licenses, Registrations:

Must be licensed or eligible for licensure as a Registered Nurse (RN) in the State of Wyoming

PHYSICAL WORKING CONDITIONS:

Minimal travel may be required.

NOTES:

FLSA: Exempt
The Wyoming Department of Workforce Services (DWS) uses E-Verify, an Internet-based system, to confirm the eligibility of all newly hired employees to work in the United States. Learn more about https://www.e-verify.gov/ , including your rights and responsibilities.
For the Veteran's preference consideration, supporting documentation must accompany your application.
Former State of Wyoming employees, who are rehired within 31 days from their previous employment, will be required to reimburse the State of Wyoming for all Vacation and Sick leave compensation received upon separation.
Offers of employment will be contingent upon the successful completion of a background check.

053-Department of Workforce Services - Administration - Workers' Safety & Compensation

Click here to view the State of Wyoming Classification and Pay Structure.

URL: http://agency.governmentjobs.com/wyoming/default.cfm

The State of Wyoming is an Equal Opportunity Employer and actively supports the ADA and reasonably accommodates qualified applicants with disabilities.

Class Specifications are subject to change; please refer to the A & I HRD Website to ensure that you have the most recent version.

SOMC10-2024-00848-RN Medical Case Reviewer-Cheyenne

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