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Worker's Compensation Case Man...

Job Summary
  • Company
  • Location
    Raleigh, NC 27601
  • Job Type
    Full Time
  • Job Category:
  • Occupations:
    General/Other: Medical/Health
  • Years of Experience
    2+ to 5 Years
  • Career Level
    Experienced (Non-Manager)
  • Industries
    Healthcare Services
  • Education Level
    Bachelor's Degree
Provider Resources Inc - Careers
Worker's Compensation Case Manager Level II Reviewer

Workers’ Compensation Case Manager Level II Review

Reporting to the Operations Manager, the Workers’ Compensation Case Manager will provide professional assessment, planning, coordination, implementation and reporting of complex clinical data and support the medical review operations of Provider Resources, Inc (PRI).  The Workers’ Compensation Case Manager Position must meet daily productivity and QA standards.  The Workers’ Compensation Case Manager will perform comprehensive medical record reviews and evaluate Workers’ Compensation Medicare Set-Aside proposals to make recommendation to CMS for final determination based on applicable coverage policies, coding guide lines and utilization and practice guidelines.


  • Understand and represent PRI’s mission, vision, and values to all internal and external customers
  • Engage clients in appropriate communication that manages client expectations and builds a collaborative relationship with the client
  • Interact with government and private sector clients, partners, and PRI staff in a professional and accountable manner, and as a representative of PRI
  • Perform medical record and Medicare Set-Aside proposal review in accordance with all State and Federal mandated regulations
  • Provide first level response to written inquires (fax, letter and email) received and create the cases in an internal data management system
  • Meets daily production requirements; review a minimum of 3 to 5 cases daily with a QA score of 98% or above.  After a period of 3 months must review a minimum of 5 cases daily maintaining a QA score of 98% or above to ensure a quality product
  • Identify and pursue the development of documents needed
  • Participation in educating and communicating the Worker’s Compensation Medicare Set-Aside program requirements to the submitters
  • Maintain compliance with all regulation changes as they impact medical and utilization review practices
  • Analyze patient records and participate in interdisciplinary collaboration with PRI staff and all recognized teaming partners and/or subcontractors
  • Document all review information into the appropriate Medical Review form, report and/or system.  Communicate these report results to the appropriate supervisor
  • Utilize electronic health information imaging
  • Utilize Internet and Intranet resources for policy verification and state regulations
  • Utilize Mainframe shared system access to the Centers for Medicare & Medicaid Services’ (CMS), Worker’s Compensation Case Control System (WCCCS) to verify claims data information by query and search activities
  • Make clinical judgments based on clinical experience when applicable
  • Performs duties of CSR Level 1 as required
  • Perform other duties as requested



  • Bachelor's Degree in Nursing (BSN) or other related field preferred

  • Must have Medicare Set-Aside Consultant Certified (MSCC)
  • Three or more years' experience in medical/utilization review particularly with Medicaid, Workers Compensation, a commercial insurance carrier, or Medicare
  • Working knowledge of SSDI, rehabilitation, disability (STD & LTD), medical and workers' compensation benefits
  • Formal knowledge of medical/rehabilitation case management as manifested by a degree (or acceptable equivalent) as a Rehabilitation Counselor with a CRC and/or Registered Nurse, with a CCM (the following may be considered COHN, CRRN, or CDMS), as well as two years of experience in Field Case Management
  • Preferred experience as a Certified Case Manager (CCM), Life Care Planner, Certified Rehabilitation Registered Nurse (CRRN), or Qualified Rehab Provider (QRP)
  • Knowledgeable of ICD-9-CM, CPT-4 and HCPCS coding
  • Knowledge of Microsoft office suite such as Outlook, Access, Excel and Word
  • Certification in coding, utilization management/review and/or the quality improvement process preferred
  • One year or more of utilizing InterQual and/or Milliman guidelines against inpatient services experience is preferred
  • One year or more of federal and local policy applications in relation to insurance procedures for medical necessity and benefit coverage preferred
  • Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
  • Must have no conflict of interest (COI) as defined in 1154(b)(1) of the Social Security Act (SSA)
  • Ability to obtain and maintain U.S. Government Security Clearance

Qualified individuals must reside in, or be willing to relocate to, a recognized HUBZone area. (Go to www.sba.gov/hubzone for more information on this requirement).



About Us
About Provider Resources Inc
Provider Resources, Inc. (PRI), located in Erie, Pennsylvania, is 8(a) Certified, a woman-owned small business…

Mission Statement: Provider Resources, Inc., recognizing the complexity of healthcare, is dedicated to supporting the health care community with compliance and integrity issues through education and efficient, innovative processes.

Value Statement: In pursuit of our mission, we must always be mindful of the values each and every one of us must impart as individuals and together are the spirit of Provider Resources, Inc. Our values must be soundly based upon the principals of honesty, sincerity, kindness, goodness, loyalty, patience, understanding… integrity.