Description

Job Summary

Nurse Case Manager in a specialty area including but not limited to disability and psychiatry case management. Completed investigations and determinations applying various case and disability management principles within area of specialty. Ensures expeditious and effective claims decisions through collaboration with healthcare providers, physicians, therapists, claimants and claims staff. Investigates and determines claimants chronicity of illness. Utilizing claims policies and guidelines, reviews coverages, secures information, makes decisions and manages claims to mitigate risk.

Essential Duties & Responsibilities

1. Assesses disability status, makes recommendations and identifies appropriate resources.

2. Accountable for gathering, investigating, and coordinating medical evidence for evaluation of functionality and makes assessments on restrictions and limitations and assigns length of disability.

3. Consults on case management issues in area of specialty and applies effective case management interventions.

4. Collaborates with medical and other providers to ensure appropriate claim decision and management.

5. Facilitates job modifications when appropriate and educates involved parties regarding claims process and functionality as it relates to job requirements while remaining externally focused.

6. Addresses causality and refers to appropriate medical expertise.

7. Documents according to jurisdictional, departmental and accreditation requirements.

8. Analyzes and manages claims activities. Prepares and presents reports for management. May be responsible or involved for special projects and presentations.

9. Serves as clinical resource to staff for interpretation of medical records and consultation regarding medical conditions or identification of primary diagnosis.

10. Identifies short term claims and facilitates transition of claimants to independence. .

11. Develops solid knowledge of claims and insurance industry theory and practices.

May perform additional duties as assigned.

Reporting Relationship

Clinical Service Manager or Director

Skills, Knowledge & Abilities

1. Strong knowledge of case management, specialty area, medical terminology and conditions, insurance industry as well as company policies and procedures.

2. Ability to exercise professional independent judgment and assume responsibility for decisions which have an impact on people, costs and quality of service.

3. Excellent verbal, written, and presentation skills with the ability to convey technical issues in a clear, concise and effective manner.

4. Strong interpersonal skills with the ability to effectively interact with internal and external business partners.

5. Detail oriented with strong organizational and analytical skills as well as the ability to prioritize and coordinate multiple tasks.

6. Knowledge of Microsoft Office Suite as well as other business related software.

7. Ability to work independently.

8. Ability to communicate effectively.

8. Ability to adapt to change and value diverse opinions and ideas.

9. Ability to fully comprehend claim information; and to further articulate analyses of claims in internal reports.

10. Ability to handle claims with a proactive long-term view of business goals and objectives.

Education & Experience

1. RN with BSN preferred. Eligible to sit for national case management certifications.

2. Typically a minimum five years diverse clinical background, with two or more years disability management experience preferred