About the role
SUMMARY
The Senior Nurse Case Manager (SNCM) role within the Claims Department is to
assist management and the claims team in supporting strategic initiatives and
achieving annual claims goals. This position is responsible for applying medical
knowledge in reviewing complex workers’ compensation claims to determine causal
nature of patient’s symptoms, medical necessity/reasonableness of treatment,
facilitate claimants’ return to work (RTW) and propose alternative care
arrangements. SNCM assists in development of new medical cost containment
programs and projects as well as taking a leadership role in the implementation
and ongoing support of these initiatives. The SNCM utilizes competence, positive
communication skills, problem solving and conflict resolution techniques. The
SNCM demonstrates strong organization and time management skills with the
ability to affect change when necessary. This role may execute their essential
functions telephonically or as a Field NCM providing in person care and/or
coordination.
Field/Hybrid focus:
The Field SNCM Manager is responsible for managing the medical care and
facilitating return to work for injured employees. The position requires
on-site, face-to-face interaction with injured workers, providers, and employers
to facilitate appropriate, and timely care that supports recovery and return to
work.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be
assigned.
SNCM and FNCM
1. Oversee new assignments and make timely initial contacts with all parties.
2. Reviews patient clinical status and history to determine casual nature of
patient’s symptoms as related to reported work injuries.
3. Complete RN template and documentation, to include but not limited to:
pertinent medical history, exposure analysis including cost drivers such as
anticipated treatment, length of treatment, length of treatment, length of
treatment, length of treatment, length of disability and anticipated
permanency.
4. Negotiate and coordinate with employer for early return to work and/or
alternative duty based on provider’s report on employees’ abilities upon
receipt of the claim.
5. Provide oversight of all external nurse case management and external RN
task assignments. Document the strategy and anticipated cost benefit to the
claim for the assignment. Establish a mutually agreed upon plan of action
with the external NCM and a time frame for the completion of that POA.
6. Applies medical knowledge base during contacts with physicians, therapists,
etc. as necessary on any case where prolonged treatment has occurred to
assess each case.
7. Determines the medical necessity/reasonableness of proposed and ongoing
treatment as well as inpatient or outpatient hospitalization for each
lost-time case.
8. Conducts case research which may necessitate contacting or meeting with
employees, employers, physicians, medical staff members, medical
consultants, etc.
9. Appropriately refers workers’ compensation cases not meeting medical
criteria to the medical director, designated consultant or independent
physician providing supporting case documentation.
10. Formulates all internal and external correspondence necessary to research
and resolve case disputes and case inquiries, contacting providers and
involving claims representatives as required. Communicates final decision
and subsequent ramifications to claim representatives.
11. Medically manage claims in multiple jurisdictions.
12. Close assignment appropriately within internal performance standards.
13. Training and/or Mentoring nurse case managers with less experience.
14. Prepare professional presentations for prospective customers.
15. Assist manager with monthly NCM outcomes including monthly reports and
assisting with monthly quality assessment evaluations of Nurse Case
Managers if needed.
EDUCATION AND EXPERIENCE for all focuses:
1. Registered Nurse license active and unrestricted required.
2. Bachelor’s degree in nursing (BSN) preferred.
SNCM and Field:
1. Five (5) years of progressive responsibility in injury case management
(workers’ compensation, group health, auto, etc.).
2. Three (3) years of active patient or clinical experience as a RN is
required.
3. Three (3) years of workers’ compensation case management, rehab, insurance
or occupational health experience is preferred.
4. Field Case Manager experience preferred.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each
essential duty satisfactorily. The requirements listed below are
representative of the knowledge, skill, and/or ability required. Reasonable
accommodation may be made to enable individuals with disabilities to perform
the essential functions.
OTHER SKILLS AND ABILITIES
1. Knowledge of clinical care and jurisdictional requirements.
2. Must possess strong negotiation skills and decision-making ability.
3. Excellent oral and written communication, customer service, written report
preparation, human relations, negotiation and decision-making skills are
required.
4. Proficient in Microsoft Windows Suite.
5. Must be able to work independently as well as within a team.
6. Attention to detail and analytical skills required.
7. Demonstrated leadership abilities are essential.
8. Knowledge of team building and employee motivation theories with the
ability to effectively manage multi-functional employee teams.
9. Ability to work with and empower others on a collaborative basis to ensure
success of team.
10. Demonstrated ability to work independently in the research, planning,
development and implementation of corporate projects.
11. Ability to appropriately manage resources, budgets, issues and risks for
the successful completion of projects.
12. Ability to train others.
13. Establish and maintain effective working relationships with all internal
and external customers.
SNCM, Field and Medical Bill Review:
1. Strong working knowledge of workers’ compensation laws.
2. Must possess strong negotiation skills and decision-making ability.
3. Attention to detail and analytical skills required.
4. Ability to exercise good judgment in evaluating and determining the
appropriateness of various actions within the process of workers
compensation claims management.
5. Ability to read, analyze and interpret technical, legal and financial
information and procedure manuals.
6. Ability to make competent, independent decisions and maintain
confidentiality where appropriate.
7. Must be able to work independently as well as within a team.
8. Field NCMs is required to possess an unrestricted and valid driver’s
license.
PAY RANGE:
Actual compensation decision relies on the consideration of internal equity,
candidate’s skills and professional experience, geographic location, market, and
other potential factors. It is not the standard practice for an offer to be at
or near the top of the range, and therefore a reasonable estimate for this role
is between $73,600 and $123,200.
WORKING CONDITIONS:
Work is performed in an office setting or remote with no unusual hazards. SNCM
– Field will be required to travel as this is a hybrid position and requires
on-site face-to-face interaction with injured workers, providers and employers.
ADDITIONAL INFORMATION
The above statements are intended to describe the general nature and level of
work being performed by people assigned to this classification. They are not
intended to be construed as an exhaustive list of all responsibilities, duties
and skills required of personnel so classified. This job description does not
constitute a contract for employment.
We are an Equal Opportunity Employer. We will not tolerate discrimination or
harassment in any form. Candidates for the position stated above are hired on an
"at will" basis. Nothing herein is intended to create a contract.
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Source: employer career site (oraclecloud). Listed Oct 30, 2026. Confirm all details on the employer's site.