Full Job Description
The Nurse Consultant is responsible for providing support for a Chief Medical Officer (CMO) with an EK Health client. The nurse consultant delivers work through a highly collaborative process under the direction of the CMO in order to promote quality cost effective outcomes by provision of medical oversight and review of high volumes of cases.
Job Responsibilities include, but are not limited to:
Once a file is identified as needing involvement from the Nurse Consultant, activities are processed in accordance with EK’s standard and client protocols. Activities may include:
Case Reviews for UR denials, modifications, delays and approvals.
Evaluation and review of independent medical review (IMR) claims to investigate and respond to complaints related to IMR on an as needed basis.
Review of large loss cases to determine potential future treatment plans and provide recommendations on appropriate treatment.
Management of the opioid/ pharmacy management program including tracking of opioid cases and provision of recommendations for the opioid management team.
Analysis of Medical Provider Network (MPN) outcomes and peer review for MPN performance issues or complaints.
Assist with developing and implementing medical management programs.
Provide professional guidance to the client’s employees, including preparation of medical informational bulletins or reports and presentations to the employees.
Reviewing cases for life expectancy analysis
Medical review for the Clinical Help Desk.
Performing audits surrounding surgical denials, URO, NCM and others as needed.
Track data and maintain metrics for all activities.
Perform oversight and quality control of selected activities to ensure regulatory compliance and maintenance of quality standards.
Preparation of comprehensive notes or reports following any activities designated by the client.
Ensuring productivity and timeliness of reviews following EK and client departmental policies, standards and procedures.
Handling all medical information and reports as confidential information, ensuring accuracy of activities and documentation.
Attending in-service meetings and continuing education seminars, as appropriate
Utilizing effective oral communication, written communication and organization skills and demonstrates the ability to prioritize case activities
May act as preceptor for new or covering Telephonic Case Managers as requested by management
Other duties as assigned
o Graduate of an accredited school of nursing
o Valid California RN license in good standing with no restrictions (may require licensing in multiple jurisdictions)
o Baccalaureate or higher degree in nursing and/or master’s degree in a health-related field
o Working knowledge of state and federal legislation and legislative process as it related to health services/worker’s compensation as well as working knowledge or worker’s compensation/ health care services trends. Working knowledge of CARE.
o 3 years’ experience in Field Case Management and/or Workers' Compensation Case Management.
o Proficient knowledge of the current principles, techniques, methods, and procedures of current practices in the areas of worker’s comp, case management, quality assurance, and utilization review
o Working knowledge of principles and techniques to conduct research studies and interpret data as it relates to occupational and environmental health.
o Prefer COHN (Certified Occupational Health Nurse) and/or CCM (Certified Case Manager)
o Ability to research, analyze and evaluate information to make and support decisions.
o Ability to analyze issues, interpret and apply laws/regulations and policies and procedures to proactively make and support decisions
o Ability to achieve results according to objectives.
o Ability to manage multiple projects and tasks.
o Ability to develop, provide, and monitor training.
o Ability to formulate policies, procedures, and workflow processes.
o Ability to write professional and accurate reports and other communications suitable for distribution to internal and external customers
o Ability to handle stressful situations while being firm but tactful.
o Ability to resolve sensitive issues and problems.
o Ability to work independently and as a team with co-workers and management to address and resolve issues
o Ability to influence others and negotiate agreements and consensus among project partners, work peers, and other stakeholders.
o Ability to effectively work with and relate with other people
o Ability to communicate professionally and effectively, verbally and in writing, (including the ability to negotiate credibly and persuasively) with a variety of “stakeholders.
o Ability to coordinate, facilitate, and make presentations.
o High comfort level with computers and computer programs (MS Word, MS Excel, PPT, Email)
o Ability to meet deadlines in a high pressure, time sensitive environment
o Ability to lift up to 20 lbs
o Sit (approx. 75-100% of the time), stand (approx. 0-25% of the time), type (approx. 75-100% of the time) and do the job with or without reasonable accommodation
EK Health Services has built a reputation for offering superior, goal-oriented Workers' Compensation case management, utilization review, and bill review services. Our emphasis on medical excellence, superior service, impartial reporting, and case resolution is the driving force behind our consistent annual growth. We are excited about expanding our footprint across the United States as we continue to seek opportunities to Transform Managed Care.
Employees are provided with competitive compensation and benefits, including but not limited to medical, dental, vision, PTO, and 401k. Please visit our website for more information at www.ekhealth.com.
EK is an equal opportunity employer and makes all employment decisions on the basis of merit. EK does not practice, tolerate, or condone unlawful discrimination based on any protected status or the perception of such status.