Job Description

Telephonic Case Management

Join us at HIMI, part of the HEMIC Family of Companies! Voted one of Hawai`i Business' Best Places to Work for 8 Years in a Row!

As a HIMI employee, you will get:

• People Who Care
• Professional Growth
• Benefits & Perks
• Opportunity to Give Back

HIMI is a Managing General Agency and Third-Party Administrator dedicated to supporting Hawai`i's businesses through customized insurance packages and expert insurance consulting.

Our TCM plays a key role in workers' compensation claim management, overseeing treatment appropriateness and coordinating return-to-work efforts. The TCM utilizes clinical knowledge and problem-solving skills to collaborate with the claimant, physician, and claim specialist to help our claimants get back to work and back to life.

Essential Duties

• Provides telephonic nurse case management (TCM) – medical care coordination and facilitation of early return to work (RTW) in a workers' compensation environment, including triage.
• Makes timely contacts in accordance with TCM guidelines and documents all information in Guidewire Claim System and ImageRight document storage.
• Completes timely initial, status, and closing reports in compliance with TCM Guidelines.
• Assesses and documents according to clinical protocols, the treating physician's initial and ongoing treatment plan for diagnosis, symptoms, history (for example, causality, description of accident and prior history), diagnostic testing, medication, specialty referral, therapies, next appointment date, anticipated length of disability, physical status, and expected MMI.
• Conducts periodic task assignments (field) as deemed necessary and approved by Manager.
• Develops medical case management plans that ensure a balance of quality of care and cost effectiveness while making recommendations that are specific, action-oriented, and target-dated.
• Reviews medical reports/treatment plans, identifies barriers to recovery and formulates a medical case management plan to overcome these barriers. Coordinates approved treatment when appropriate, as well as diagnostics, durable medical equipment, FCEs, and transportation.
• Adheres to state-mandated treatment guidelines (Hawaii State Medical Fee Schedule).
• Addresses RTW capability with the injured worker and provider after each visit. Updates the claim specialist once information obtained and documents a brief summary in Guidewire claim system.
• Calculates and monitors the estimated length of disability/expected course of medical treatment based on Official Disability Guidelines (ODG) and communicates this information to the claim specialist.
• Works with Departmental staff in a team concept - sharing ideas, knowledge, expertise, and experience. The team concept enhances the department's overall knowledge and work quality.
• Adheres to HIMI's Best Practices and Service Standards.
• Requires daily oral and written communication with injured workers, claim specialists, insureds, medical providers and any other stakeholders deemed pertinent to the injured worker's successful return to preinjury status.
• Maintains ongoing professional training and development and applicable professional certifications.
• Other duties as assigned.

Requirements

• Valid RN license required. BSN (preferred). ADN may apply.
• 1-3 years of experience in nurse case management, preferably in occupational medicine, rehabilitation, managed care, or acute hospital settings.
• Proficiency with Microsoft Office (Outlook, Excel, Word).
• Proficient medical analytical skills.
• Proactive, resourceful, and diplomatic with the ability to succeed in a team environment.
• Excellent communication skills (phone, written, oral), customer service, decision-making, time management/organizational skills, use of discretion and judgment.
• CCM, CDMS, CIRSC and/or COHN (preferred).

Department - HIMI – TPA

Work Arrangement - In-Person, HEMIC Tower

Reports To - Executive Claims Administrator

Direct Reports - N/A

FLSA Status - Exempt Non-Exempt Job Class: 2-Prof

Approved By: clewis

Date Approved: 9/3/25

Reviewed: 8/25/26

NOTE: The above information on this job description has been designed to indicate the general nature and level of work performed by an employee in this classification. It is not to be interpreted as a comprehensive inventory, or all duties, responsibilities, and qualification of employees assigned to this job. Management has the right to add, revise or delete information in this description. Reasonable accommodations will be made to enable qualified individuals with disabilities to perform the essential duties of this position.

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