Medical Case Examiner

2 days ago

Toronto, Canada Zurich Insurance Full time

Job Summary- With moderate direction, facilitates the policyholder injured employees’ medical treatment to ensure quality, effective and cost-efficient care. Coordinates with vendors of rehabilitative services to confirm that services are consistent with the injury and the goal of returning the injured person to employability and normal activities or maximum medical improvement.- Job Qualifications- Required:
- Bachelors Degree and 2 or more years of experience in the Clinical In Medical, Surgical, Orthopedic, Neuro-Surgery area

AND- Case Management
- CRRN
- CDMS
- CCM
- CRC

**Vocational Rehabilitation Case Manager- Bachelors Degree and 2 or more years of experience in the Medical area

AND- 2 or more years of disability of workers’ compensation experience as a rehabilitation counselor
- Certified in ergonomic assessment

Preferred:
- Experience in insurance industry, workers compensation, and/or managed care
- Strong verbal and written communication skills
- Experience working in a team-based environment coordinating client care
- Microsoft Office skills

**Vocational Rehabilitation Case Manager- VRC, CRC, CDMS or CCM
- Experience in insurance industry, workers compensation, and/or managed care
- Strong verbal and written communication skills
- Experience working in a team-based environment coordinating client care
- Microsoft Office skills

Job Accountabilities - Key Accountabilities- Ensure customer satisfaction by making contact with the client, medical provider and claim professional in a timely manner and according to Best Practices.
- Ensure customer service by proactively communicating information; responding to inquiries; and following customer specific protocols.
- Establish a case management plan by completing evaluation and recommend plan of action.
- Coordinate and communicate activities of the case management plan by maintaining ongoing communication with client, provider(s), and claim professional as appropriate and according to Best Practices.
- Manage activities associated with case by completing assignments from claims staff, utilizing Managed Care tools (Preferred Provider Organizations, preferred vendors), addressing issues and escalating as appropriate.
- Document information according to Best Practices (including case assessment, case management plan, follow-up communication, closure, billing, cost containment and return to work data).
- Meet quality standards by following best practices.
- Manage appropriate case load according to policy and ensure accurate billing of all case management activity.
- Ensure legal compliance by following state and federal laws and regulations and internal control requirements.
- Acts as a technical resources by participating in presentations and provide education/ training sessions as needed, and/ or as requested by Manager.
- Maintain professional and technical knowledge by participating in educational opportunities, staying current with industry trends, establishing personal networks, and participating in professional societies.
- Contribute to the team effort by accomplishing related results and participating on projects as needed.
- Protect Zurich’s reputation by keeping claims information confidential.
- Maintain professional and technical knowledge by participating in educational opportunities, staying current with industry trends, establishing personal networks, and participating in professional societies.
- Contribute to the team effort by accomplishing related results and participating on projects as needed.

Business Accountabilities- Anticipate, recognize and respond timely to needs of customers to ensure customer satisfaction.
- Support implementation of customer initiatives to drive best outcomes.
- Provide status updates on case management plan to ensure clear communications and transparency.
- Resolve technical problems by referring to policies, procedures, specifications to ensure accuracy and operational consistency.
- Identify and follow main principles relevant to medical regulatory controls that govern standard work practices to ensure compliance.
- Collect data and prepare reports including commentary and an analysis of trends to facilitate decision-making.
- Provide detailed procedural advice to internal clients to ensure that internal standards are adhered to.
- Input relevant data into established systems accurately to allow for data analysis.
- Analyze data using pre-determined tools, methods and formats and make recommendations in order to support the department’s timely resolution of claims.

Competencies- Collaborate Together- Develop & Grow- Puts Customers First- Fuel Innovation- Technical Competency 1- Technical Competency 2- Motivational fit- Provide Clear Direction- Make it Happen

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