Job Summary

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.


Occasional office visits may be required. A California RN license is required.


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


Requirements

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 Experience in Workers' Compensation Utilization Review

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)