Career opportunity with WCRC

Medicare Set-Aside Blog, News and Events on July 29, 2013
Posted by Ryan Roth

Position: Workers’ Compensation Case Manager – Level II Review

Provider Resources, Inc. (PRI) is the new Workers’ Compensation Review Contractor (WCRC) for the Centers for Medicare and Medicaid Services (CMS) and is seeking exceptionally talented and innovative Healthcare Professionals to support this program. PRI is now pursuing to hire individuals that have national reputations in the field of workers’ compensation. PRI is seeking to hire a Workers’ Compensation Quality Assurance Manager, an Assistant Operations Manager, and multiple Workers’ Compensation Case Managers.

PRI completes independent reviews of Workers’ Compensation Medicare Set-Aside Arrangements (WCMSA) to protect the best interest of the Medicare Trust Fund and its beneficiaries. Through PRI’s innovative small business format, and its mission dedicated to support the healthcare community, PRI has been able to attract and retain nationally recognized healthcare professionals specializing in education, policy, quality, and integrity. PRI looks for fundamental values within candidates that are consistent with its culture, including, basic principles of honesty, sincerity, kindness, goodness, loyalty, patience, understanding, and above all integrity. If you wish to join a team of knowledgeable and caring healthcare professionals please apply by forwarding a letter of intent to Shawn Keough-Hartz, CHBME and a resume or curriculum vitae to

Position Description: Workers’ Compensation Case Manager

Level II Review

Reporting to the Operations Manager, the Workers’ Compensation Case Managerwill 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

§ Identify and pursue the development of documents needed

§ 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

§ Participation in educating and communicating the Workers’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), Workers’ 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

§ Will give consideration to equivalent combination of education and experience in processing Medicare Set-Aside proposals in lieu of a BSN degree

§ 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

About Us:

Provider Resources, Inc. (PRI), an 8(a) Certified, woman-owned, small disadvantaged business is located in Erie, PA. PRI uses innovative ideas to improve the public’s health through education, policy change, and improvements in healthcare quality and integrity all while decreasing healthcare costs. PRI’s multiple divisions have developed programs and solutions that benefit the stakeholder community including beneficiaries, medical providers, and insurance carriers, by working with a variety of governmental programs such as:

· Centers for Medicare & Medicaid Services (CMS)

· Agency for Healthcare Research and Quality (AHRQ)

· Health and Human Services/Office of the Inspector General (HHS/OIG)

· National Institutes of Health (NIH)

· Health Resources and Services Administration (HRSA)

· Veterans Administrations (VA)

· Office of the Inspector General/United States Postal Service (OIG/USPS)

National relocation not required.

Provider Resources Inc is an Equal Opportunity Employer M/F/D/V’-Compensation-Case-Manager-Job-US-124042439.aspx