Medical Case Reviewer
State of Wyoming
Description And Functions
GENERAL DESCRIPTION
The Wyoming Department of Workforce Services is seeking a Nurse Case Manager to coordinate, evaluate, and monitor medical care services provided to injured workers receiving benefits under the Workers’ Compensation system. This position works closely with healthcare providers, employers, and division professionals to coordinate treatment plans and support injured workers in returning to their pre-injury level of functioning and employment.
Responsibilities include evaluating claimant needs and medical records to direct medical case management activities and ensuring that appropriate medical care is delivered in compliance with division statutes, rules, regulations, and treatment guidelines. The position performs medical review screenings on pre-authorization requests for surgical procedures, obtains and reviews supporting medical documentation, and refers cases for peer review when indicated.
Additional duties include documenting all interactions, reviews, approvals, and denials within the claims management system; reviewing CPT and ICD-10 codes and surgical descriptions for accuracy; and maintaining tracking systems for pre-authorizations, surgical procedures, clinical bills, and prescription requests. The Nurse Case Manager also reviews provider requests for compliance with treatment guidelines and serves as a medical resource for claims analysts by preparing medical questions for various evaluations.
This position further reviews medical bills, prescription requests, urinalysis drug screens (UDS), chiropractic and physical therapy treatments, and durable medical equipment (DME) requests to determine medical relatedness and appropriateness of care.
Laramie County is located in the southeast corner of Wyoming. Around the world, the very name
Cheyenne conjures up images of cowboys, trains, and the great outdoors. Today's Cheyenne is all of that and more! We'll always be here, ready to outfit you in new boots and hats, to point out the Wild-West history in our unique downtown, and to set you front and center at the world's largest outdoor rodeo.
Working for the State of Wyoming offers more than a paycheck. Our total compensation package includes:
- Comprehensive health, dental, and vision insurance
- Paid vacation, sick leave, FMLA, and holidays
- Retirement - Pension and 457B plans that help you build a secure future
- Flexible schedules and work-life balance options
- Meaningful work that makes a difference for Wyoming communities
- and MUCH MORE!
Click here for detailed information, or you can watch this short video to learn about our benefit package!
Want to see the full value of your compensation beyond salary? Explore our Total Compensation Calculator: https://compensationcalculator.wyo.gov
Human Resource Contact: ***email_hidden***
ESSENTIAL FUNCTIONS: The listed functions are illustrative only and are not intended to describe every function that may be performed at the job level.
- Evaluate the claimant's needs and medical records to direct medical case management activities.
- Provide assistance to healthcare providers, employers, and division professionals in coordinating care and treatment plans.
- Ensure that appropriate medical care is delivered to injured workers in a manner that is consistent with the statutes, rules, and regulations of the division.
- Perform a medical review screening on pre-authorization requests for proposed surgical procedures.
- Obtain all medical documentation to accompany the pre-authorization requests.
- Refer cases for peer review as indicated by treatment guidelines and medical reviews.
- Document all interactions, reviews, approvals, and denials in the claims management system.
- Review CPT and ICD-10 codes and surgical descriptions for accuracy on pre-authorization requests.
- Review medical documentation utilizing the Division's treatment guidelines for surgical procedures.
- Maintain tracking of all pre-authorization referrals, surgical procedures, clinical bills, and prescription requests
- Review pre-authorization provider requests for compliance with treatment guidelines.
- Act as a medical resource for claims analysts; write medical questions for multiple types of evaluations.
- Review medical bills, prescription requests, UDS, chiro/PT treatments, and DME for relatedness.
Qualifications
KNOWLEDGE
- Knowledge of community resources.
- Skills in counseling and consultation.
- Ability to apply principles of nursing, particularly medical terminology, and physical and psychosocial principles.
- Ability to interpret diagnostic testing.
- Ability to critically analyze data.
Education
MINIMUM QUALIFICATIONS
Bachelor's Degree (typically in Nursing)
Experience
1-2 years of progressive work experience (typically in Nursing)
Certificates, Licenses, Registrations:
Must be licensed or eligible for licensure as a Registered Nurse (RN) in the State of Wyoming
OR
Education & Experience Substitution
4-6 years of progressive work experience (typically in Nursing)
Certificates, Licenses, Registrations:
Must be licensed or eligible for licensure as a Registered Nurse (RN) in the State of Wyoming
Necessary Special Requirements
PHYSICAL WORKING CONDITIONS
- Minimal travel may be required.
NOTES
- FLSA: Exempt
- The Wyoming Department of Workforce Services (DWS) uses E-Verify, an Internet-based system, to confirm the eligibility of all newly hired employees to work in the United States. Learn more about https://www.e-verify.gov/, including your rights and responsibilities.
- For the Veteran's preference consideration, supporting documentation must accompany your application.
- Former State of Wyoming employees, who are rehired within 31 days from their previous employment, will be required to reimburse the State of Wyoming for all Vacation and Sick leave compensation received upon separation.
- Offers of employment will be contingent upon the successful completion of a background check.
Supplemental Information
053-Department of Workforce Services - Administration - Workers' Safety & Compensation
Click here to view the State of Wyoming Classification and Pay Structure.
Click here to view the State of Wyoming Total Compensation Calculator.
URL: http://agency.governmentjobs.com/wyoming/default.cfm
The State of Wyoming is an Equal Opportunity Employer and actively supports the ADA and reasonably accommodates qualified applicants with disabilities.
Class Specifications are subject to change; please refer to the A & I HRD Website to ensure that you have the most recent version.
Working for the State of Wyoming means more than a job — it’s a stable, rewarding career that lets you make a difference while enjoying a great quality of life.
Employees Enjoy
- Comprehensive health coverage – medical, dental, and vision plans for you and your family
- Voluntary Benefits – including life insurance for you and family members, ambulance, pet insurance, short/long-term disability, flex spending and health savings accounts
- Multiple retirement options – including the Wyoming Retirement System and a 457B account, helping you plan for long-term financial security
- Generous paid leave and flexible schedules – vacation, sick leave, paid FMLA and 11 paid holidays each year
- Public Service Loan Forgiveness eligibility – for those with qualifying student loans
- Training and professional development – to support your career growth and advancement
- Employee Assistance Program – Includes paid short-term counseling, legal, financial and work-life benefits and select employee discounts
- Wellness Program – Earn paid time off and incentives by focusing on your personal health
Know your full value.
Your paycheck is only part of the picture. The State of Wyoming offers a Total Compensation Calculator that shows the full value of your salary plus benefits, so you can clearly see what your complete compensation package looks like.
Explore your total compensation: https://compensationcalculator.wyo.gov/
WORKING FOR THE GREATEST STATE IN THE NATION - Wyoming offers a lifestyle you can’t find anywhere else — wide-open spaces, clean air, friendly communities, year-round recreation, and no state income tax.
Click here for detailed information or you can watch this short video to learn about our benefit package! .
(AA) Which of the following best describes your highest completed level of education to date or within the next three (3 months)? (Transcripts may be required.)
- High School Diploma/GED/or Equivalent
- Some college Coursework, No Degree Received
- Associate's Degree
- Associate's Degree and additional coursework
- Bachelor's Degree
- Bachelor's Degree and additional coursework
- Master's Degree
- Master's Degree and additional coursework
- Doctorate Degree
- Doctorate Degree and additional coursework
- None of the Above
(AA) Which of the following Quarter/Semester credit hours best describes your completed college education to date or within the next three (3 months)? (Transcripts may be required.)
- 45+ Quarter hours/30+ Semester hours
- 90+ Quarter hours/60+ Semester hours
- 136+ Quarter hours/91+ Semester hours
- 180+ Quarter hours/120+ Semester hours
- 225+ Quarter hours/150+Semester hours
- N/A
(SOMC10) How many years of relevant work experience or transferable skills do you have related to the job description?
- No relevant experience.
- Less than one (1) year of relevant experience.
- One (1) to less than three (3) years of relevant experience.
- Three (3) to less than four (4) years of relevant experience.
- Four (4) or more years of relevant experience.
(AA) Describe your relevant experience in the box below.
(SOMC10) Do you currently possess or are you eligible for licensure as a Registered Nurse (RN) in the State of Wyoming?
- Yes
- No
(SOMC10) Please provide your license no. in the box below.
Describe how you have applied the principles of nursing to your past work assignments. Specifically, demonstrate the role that medical terminology, physical and psychosocial principles have been applied.
Describe the types of diagnostic testing you have interpreted, including the amount of time spent on this activity and how the data was applied to duties to be performed.
Describe community resources you are aware of that might offer assistance to injured or disabled individuals.
Summarize your skills and experience in counseling and consultation. Include Information on the type of conditions and patients included in your summary.
Describe how you have applied critical analysis to available information regarding a patient's condition to arrive at a treatment plan for that condition. Include information demonstrating how you determined the correct protocol in these instances.
(DWS) Former State of Wyoming employees rehired within 31 days of their previous employment with the State will be required to repay any Sick and Annual leave payouts.
- I am a former State of Wyoming employee and I have read and understand the above statement.
- I am not a former State of Wyoming employee.
(DWS) The Wyoming Department of Workforce Services (DWS) uses E-Verify, an Internet-based system, to confirm the eligibility of all newly hired employees to work in the United States. Learn more about E-Verify, including your rights and responsibilities. I have read and understand the above statement.
- Yes
- No
(A1) Where did you hear about this opportunity?
- Government Jobs @ www.governmentjobs.com/careers/wyoming
- Indeed
- Zip Recruiter
- Wyoming Workforce Center
- Other job sites (Wyoming at Work, Monster, etc.)
- Social Media (Facebook, Twitter, etc.)
- Newspaper/Newsletter Advertisement
- Career Fair
- Human Resources Division
- Friend or Acquaintance (Not State Employee)
- Current State Employee
- Other
(A1) If you selected "Current State Employee" please provide the employee's first and last name, and include the department they work for, if known. This employee may be eligible for a Referral bonus.
(AA) If you anwsered Other, please tell us where.
(AA) VETERANS' PREFERENCE DISCLOSURE: PER WYOMING STATUTE, current employees of the State of Wyoming are not eligible for veterans' preference. If you are not a current employee of the State of Wyoming, to be eligible to receive veterans' preference you MUST have been a resident of the State of Wyoming for a period of one (1) year or more at any time prior to submitting this application. I have read and understand the veterans' preference disclosure.
- Yes
- No
- I am not a veteran
(AA) VETERANS' PREFERENCE: If you are a war veteran as defined in section 101, Title 38, United States Code or are the surviving spouse of a war veteran who receives survivor benefits from the federal government based on the veteran's military service, and wish to claim veterans' preference, please attach the appropriate documentation substantiating your claim. Indicate below your appropriate veterans' preference status. By requesting veterans' preference, you are certifying that you meet the statutory requirements as described in the above disclosure.
- Current State Employee
- Veteran - DD214 Attached
- Disabled Veteran (10% or more) - DD214 and Veteran's Disability Determination Attached
- Surviving Spouse of a Deceased Veteran - DD214 and proof of Survivor Benefit Attached
- None of the above
(AA) Please be advised that an incomplete application WILL NOT be considered for employment. An attached resume' is not required and is not an acceptable substitution for a completed application. Some State of Wyoming agencies use E-Verify, an Internet-based system, to confirm the eligibility of all newly hired employees to work in the United States. Learn more about E-Verify, including your rights and responsibilities at https://www.uscis.gov/e-verify. I have read and understand the above statement.
- Yes
- No
(DWS) Please be advised that any offers of employment will be contingent upon the successful completion of a background check. I have read and understand the above statement.
- Yes
- No
- Required Question
