Independent Case Manager REGISTRATION
Fields with * are REQUIRED
 
ACCOUNT STATUS
 
CHOOSE WHETHER TO MAKE YOUR ACCOUNT ACTIVE OR INACTIVE:   
 
CONTACT INFORMATION
   
For those Independent Case Managers that do not have a company name, you will need to enter your own name in the "Company Name" box.
   
*COMPANY NAME:   
*CONTACT NAME:   
*PHONE:  
FAX:  
*ADDRESS LINE 1:  
ADDRESS LINE 2:  
*CITY:  
*STATE:  
*ZIP:  
*E-MAIL:   
 
Enter a password. You will need the password later to update your information.
Your password is limited to a maximum of 12 characters
 
*PASSWORD:  
*ENTER PASSWORD AGAIN:  
 
SERVICES OFFERED
 
SERVICES OFFERED IN WHAT LOCATIONS:
(You may choose as many locations as apply)
(To choose multiple locations, left click your mouse button while holding down the keyboard control key)
 
 
SERVICES OFFERED:
(Check each type of Service or Job Title that applies. You must select at least one.)
 
 
Medical Management / Catastrophic CM
PIP / Workers Comp Case Management
Business Development Consultant
Marketing Specialist / Contract Negotiations
Case Mgmt Department Startup / Staff Development
Medical / Legal
Consultant
Hospital Bill Audit
Medical Chart Review
Other
 
QUALIFICATIONS
 
CERTIFICATIONS HELD:
 
EDUCATION:
 
 
AREAS OF CLINICAL EXPERTISE:
(Choose all that apply)
 
 
Pediatric / NeoNatal
Geriatrics
AIDs
Transplantation / Adult - Pediatric
Pain
Wound Care
Spinal Cord Injury
Closed Head Injury / Traumatic Brain Injury
Psych
Oncology
Other
 
SPECIAL SKILLS:
(Choose all that apply)
 
 
Workers Compensation Law
NCQA
HCFA
Interqual Criteria
Milliman Robertson
ICD-9
CPT Codes
Risk Management
Strategic Planning
Cost Containment
JCAHO Accreditation
Medical / Legal / Expert Witness
FMLA
Managed Care
Contract Negotiations
Other
Long Term Care Assessments
 
COMPANY WRITE-UP
 
Short Company write up
(Limited to approx. 200 words or less)
 
 
 
 
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