Req #19714 For more than 170 years, The Hanover has been committed to delivering on our promises and being there when it matters the most. We live our values every day, demonstrating we CARE through our values, Sustainability initiatives and inclusive corporate culture.   We are excited to announce an opportunity to join our medical strategy team as a Nurse Case Manager. This full‑time, exempt position offers the flexibility of working remotely while contributing to a high‑impact, growing team.   Position Overview: Responsible to provide case management coordination for claimants with compensable injuries. Participate collaboratively with various members of claims team, treatment providers and network vendors.   Responsibilities/Essential Functions:

• Negotiates fees with vocational rehabilitation, medical case management and DME vendors. Coordinates and monitors referrals to rehabilitation and medical case management vendors. Coordinates services as indicated with HIG Utilization Review department nursing staff.
• Gathers, compiles, analyzes and reports service data significant to clients
• Acts as resource to claims professionals, underwriting and account representatives for identification of appropriate medical services, goods and providers
•  Coordinates MDL requirements for ongoing certification
• Reviews and determines need for an Independent Medical Exam, including area of medical specialty
• Assists in projection of reserves for the life of the claim and collaborates with adjuster for Roundtables. Assesses healthcare needs associated with compensable/covered illness/injury claims and comorbidities. Coordinates and arranges for cost effective service delivery that is consistent with the claimant's health care requirements and policy benefits
• Educates and evaluates injured/ill claimant/class member, insured party, and health care provider regarding patient's response to treatment to enhance claimant adherence and progress toward maximum medical improvement as well as Return to Work planning.
• Monitors and evaluates claimants' responses to medical treatment and progress in recovery, and makes recommendations for alternative treatment or care options if needed.
• Collaborates with treatment providers and claimant for cost effective medical treatment. Assists with removing roadblocks to treatment adherence by the claimant or insured party.
• Coordinates and monitors clinical treatment services such as discharge planning, medical specialty referrals, and vendor needs. This may include inpatient and outpatient services, MDs, home care, attendant care, and/or network partners for ancillary services.
• Evaluates the components of the injured/ill claimant's job with claimant and employer and, if appropriate, clarifies the critical demands of the job and suggests any necessary modifications or accommodations to comply with government regulations (in WC/PIP claims) with a focus on ability and return to work.
• Reports electronic data for utilization of NCM resources and claimant progress and outcomes with HIG guidelines and software programs. May assist/direct clients in applying for social security disability Participate and prepare educational presentations to nursing peers and claims department staff as needed.

Skills, Key Success Factors and Experience:

• Registered nurse with current state licensure
• Certified Case Manager certification preferred
• Minimum of three years of clinical experience in applicable nursing specialty field (i.e. occupational health, rehabilitation, orthopedics, home care, emergency, etc.)
• Working knowledge of utilization review process, medical bill review and/or medical case management
• Ability to collaborate and work effectively in a team environment
• Strong analytical, problem solving and negotiation skills
• Effective interpersonal communication and writing skills
• Organization skills with regard to time management, task prioritization, and integration of information from a variety of sources
• Ability to determine and meet internal and external customer needs
• Word processing skills
• Fluent in English
• Knowledge of technical materials, rules, procedures or facts required to effectively performing the role such as : utilization criteria (Intermural), medical coding mechanisms( ICD-9 CM, CPT-4, DSM-IV), case management standards of practice, state workers' compensation and personal injury protection (PIP) regulations
• Ability to adapt to a dynamic work environment
• PC/ Keyboard skills

Physical Demands and Work Environment:

• Ability to use a personal computer and other standard office equipment
• Ability to travel as necessary
• Ability to sit and/or stand for extended periods

CAREER DEVELOPMENT: It’s not just a job, it’s a career, and we are here to support you every step of the way. We want you to be successful and fulfilled. Through on-the-job experiences, personalized coaching and our robust learning and development programs, we encourage you – at every level – to grow and develop.   BENEFITS: We offer comprehensive benefits to help you be healthy, build financial security, and balance work and home life. At The Hanover, you’ll enjoy what you do and have the support you need to succeed.   Benefits include:

• Medical, dental, vision, life, and disability insurance
• 401K with a company match
• Tuition reimbursement
• PTO
• Company paid holidays
• Flexible work arrangements
• Cultural Awareness Day in support of IDE
• On-site medical/wellness center (Worcester only)
• Click here for the full list of Benefits

EEO statement: The Hanover values diversity in the workplace and among our customers.  The company provides equal opportunity for employment and promotion to all qualified employees and applicants on the basis of experience, training, education, and ability to do the available work without regard to race, religion, color, age, sex/gender, sexual orientation, national origin, gender identity, disability, marital status, veteran status, genetic information, ancestry or any other status protected by law. Furthermore, The Hanover Insurance Group is committed to providing an equal opportunity workplace that is free of discrimination and harassment based on national origin, race, color, religion, gender, ancestry, age, sexual orientation, gender identity, disability, marital status, veteran status, genetic information or any other status protected by law.” As an equal opportunity employer, Hanover does not discriminate against qualified individuals with disabilities.  Individuals with disabilities who wish to request a reasonable accommodation to participate in the job application or interview process, or to perform essential job functions, should contact us at:HRServices@hanover.com and include the link of the job posting in which you are interested.   Privacy Policy: To view our privacy policy and online privacy statement, click here. Applicants who are California residents: To see the types of information we may collect from applicants and employees and how we use it, please click here. Compensation: The target hiring range for this role may vary based on geographic location and other factors, including merit or performance, demonstrated proficiency, skills for the role, education, travel requirements, and experience. Additional compensation may include an annual bonus (which could take the form of a general bonus, sales incentive, or short-term incentive), long-term incentive or spot recognition awards. The posted range reflects our ability to hire at different position titles and levels depending on background and experience.

Job Details

Job Family Claims - Medical Strategy Job Function Claims Pay Type Salary Hiring Min Rate 85,000 USD Hiring Max Rate 95,000 USD