Nurse Case Manager

Job description
Europ Assistance Canada, part of Generali Group (www.generali.com), is looking for a Nurse Case Manager to join our Medical Assistance team in Canada, who can contribute to the building of local Canadian operations.

Europ Assistance (https://www.europ-assistance.ca) is a global company, active in over 200 countries and territories in the delivery of our products and services.

The Canadian business unit will strategically focus its efforts on the Travel Insurance industry with the distribution of product offerings and associated medical assistance services to key stakeholders for their customers traveling abroad or within Canada.

This role will report into the Head of Medical Assistance and is based in Toronto, with the working environment being a mix of in-office and remote work, though always in close collaboration with colleagues and stakeholders.

Summary:

The Nurse Case Manager is a Registered Nurse who is accountable and capable of securing and reviewing clinical data (historic and real-time) to approve requests for admissions, procedures and services that meet clinical review criteria. Ensures that there is coordination and delegation of care between all providers involved. Ensure that procedures/services are not duplicated and that services being rendered fall within the industry standards of care.

The Nurse Case Manager’s responsibilities include but are not limited to:
• Assessment of strengths and weaknesses of relevant provider(s)
• Implementation of a treatment plan
• Coordination and availability of resources, familiarity with the insured policy and its’ limitations and the communication and documentation with the appropriate entities that require information as per the stated policies and procedures while adhering to PIPEDA and/or GDPR and/or HIPAA compliance.
• Knowing when to escalate to supervising MD

Responsibilities Include:
• Performs Utilization Review/Utilization Management (UR/UM) and Case Management duties according to company policy and procedure.
• Collects client data and conducts emergent and non-emergent clinical assessment (historic and real-time).
• Assists in the referral of patients when and where clinically indicated to most appropriate provider specialty/facility within Network, ensuring alignment with ALL stakeholders.
• Monitors and screens pre-authorization requests for second medical opinion referrals and/or diagnostic testing and/or transfers.
• Reviews hospital admissions for medical necessity and determines length of stay (LOS) in accordance with established criteria. Sends out and maintains appropriate communication, inclusive of expectations and updates to providers, facilities and/or client.
• Refers all cases that do not fall within pre-established criteria to the supervisor for further evaluation and determination of admission approval, procedure or services requested or refers to Medical Director or peer reviewer.
• Nurse Case Managers do not issue non-certifications (denials). Once it is determined that an admission, procedure or service should be denied; assists in assuring that verbal or written denial notices, authored by leadership, are distributed out to the appropriate parties in a timely manner.
• Performs duties of the discharge planning nurse to contain LOS and assure that the insured (member/patient) is, at the very least, receiving services within the 6 Rights: Care, Place, Time, Provider, Price and Outcome.
• Assist with the coordination (within all phases) of a repatriation/evacuation and work in accordance to individual Client Procedures as well as Standard Operating Procedures. Through regular monitoring, report and escalate any change in insureds (member/patient) condition IMMEDIATELY in order to make any differing change in plans.
• Enters and maintains, in real-time, all applicable information related to a case in EA Canada’s case management operating system (SAX software).
• Attends and participates in all departmental meetings as scheduled. Coordinates data collection and reporting, inclusive of next steps, for meetings, as deemed appropriate.
• Evaluates and reviews treatment plan for consistency of care. Develops realistic treatment plan with expectations in collaboration with provider recommendations to meet the client’s needs while providing the most appropriate and cost-effective method of delivering services. Any deviation by treating provider from our service policies/procedures is to be escalated immediately to supervising MD.
• Performs written and oral communication with other Europ Assistance (EA) Canada, EA entities, Generali Global Assistance (GMMI) and (GPPO) staff to (transparently) provide case information, recommendations based on medical necessity, policy language and cost indexes to clients.
• Evaluates and determines the availability of most appropriate resources in conjunction with policy limits and coverage. Implements cost management and delivers the most effective treatment plan.
• Maintains current knowledge base with regard to medical-surgical cases, utilization management, discharge planning and continued care needs in relation to physician approved criteria. Case Manager is to expand knowledge base and become familiar with the value of ICD-10 and how it improves cost containment efforts due to increasing the accuracy of payments and reducing unpaid claims.
• Reports any concerns, problems, and quality assurance issues, in real-time, with the correct Department Head for further evaluation and possible intervention. Follows up with corrective action on recommendations made when required.
• Responsible for updating the “Tracker” system and for the timely follow up on each case that is monitored in the tracker.
• Participates in issuing non-conformance and corrective actions when quality issues or disruptions in services or systems are identified (proactive thinking). Mindset: How can I improve the process and/or the outcome? How will this event not be repeated?
• Functions as a clinical resource to non-clinical staff.

Education, knowledge, Skills, and Abilities Required:
• Nurse Case Managers need to possess at least four-year experience in the field of Managed Care or related acute care areas; CCU/ICU, Critical Care, ER.
• Bachelor of Science in Nursing (BScN) Degree
• Licensed health professionals: Active (unrestricted) registration with the College of Nurses of Ontario.
• Maintains confidentiality of all pertinent client/member (patient) information.
• Moderate computer literacy required
• Strong organizational and time management skills required – with emphasis on prioritizing and performing multiple tasks in unison.
• Excellent communication skills (verbal and written).
• Effective and sound decision making and problem-solving skills a must.
• Ability to work both independently and in a group setting.
• Exercises and displays the ability to interact effectively with physicians, providers, internal staff and insureds’ as deemed necessary
• Able to work in a multicultural environment and manage a diverse client/patient population is required.
• Functions as an “ambassador” for the company demonstrating public relations skills.
• Providing training to non-medical case managers to improve their learning and case management skills

Flexible Language Requirement:
• Bilingual French/English (any other language is an asset).

Work Location: Toronto office - Regular and reliable attendance under a hybrid model.

Europ Assistance Canada Services Inc. supports all accommodation requests from applicants with disabilities; please contact Human Resources at careers@europ-assistance.ca if any accommodation is required.

We thank all applications for their interest, but only candidates selected for an interview will be contacted. Read more