Case Manager

Ullico•Silver Spring, MD

12d•Onsite

About The Position

Union Labor Life Insurance Company is actively recruiting a Case Manager for our Silver Spring, MD office. This role involves analyzing financial exposure in claims, reviewing medical necessity, gathering clinical information, and communicating complex clinical data to non-clinical stakeholders. The Case Manager will apply clinical knowledge to make determinations of medical necessity, troubleshoot complex clinical problems independently, and manage high-risk individuals and transplant losses. The position also focuses on cost containment through negotiation and managing Stop Loss claims, and providing clinical insights to Underwriting, Actuarial, and Finance departments. Additionally, the role involves evaluating group claim information for renewals and new business, preparing monthly reports on large case management, and handling telephone inquiries.

Requirements

Bachelor of Science in Nursing (BSN) or higher.
Active RN license or APRN license.
Five plus years of significant clinical experience, with backgrounds in acute or critical care being highly valued.
Minimum of 5 years of clinical experience required; experience in acute or critical care strongly preferred.
Broad range of HIPAA regulations required.
Knowledge and hands-on experience with PC; Word, Excel required.
Demonstrated customer service skills.
Demonstrated oral and written communication skills with all levels of personnel.
Demonstrated ability in multi-tasking.

Nice To Haves

Familiarity with Connexure ESL platform a plus.

Responsibilities

Analyze “trigger reports” and high dollar claim referrals to identify potential financial exposure early in the claims process.
Review the medical necessity and appropriateness of hospital claims, physician charges, specialty drug costs, usage and provide potential alternatives.
Gather and analyze clinical information and medical records from all providers for cost containment and future cost determination by maintaining a close working relationship with plan administrators, vendors, third party payers, employers, re-insurers, and other social, psychological, and medical health care providers.
Translate complex clinical information from medical reference books, patient medical records, charges, summary plan descriptions, and stop loss insurance benefits into clear, actionable reporting to evaluate liability/compensability and to make recommendations to non-clinical stakeholders.
Compose clinical correspondence and communicate effectively with employees, employers (clients), TPA claims administrators, health care providers, claims and underwriting staff and executive management regarding current care and care alternatives.
Apply clinical knowledge to make determinations of medical necessity.
Troubleshoot complex clinical problems and practice independently without supervision of another licensed professional.
Apply clinical expertise to make determinations of medical necessity and manage complex clinical issues while practicing independently without supervision from another licensed professional.
Assess medical needs, care requirements and alternatives; monitor and follow up with the Plan Administrator, provider, etc. regarding the planning, coordination and progress of treatment; evaluate and suggest other treatment and facility alternatives as appropriate to facilitate quality, cost-effective medical care for high-risk individuals, trigger diagnoses and transplant losses.
Provide cost containment by managing an inventory of Stop Loss claims (involving large case management, trigger diagnosis or transplant network losses), securing additional discounts from providers (either directly or through a preferred vendor), negotiating prices for medical services and supplies, negotiating settlements, developing transplant networks, evaluating losses, consulting with claims examiners about appropriateness of charges and educating clients and stop loss team about cost-effective alternatives.
Work closely with Underwriting, Actuarial, Finance and other areas of the organization to provide clinical insights that inform policy pricing and reserve setting.
Evaluate group claim information at the time of renewal and new business and provide underwriters with an estimated projection of expected claim dollars in the next policy period.
Prepare monthly report on all large case management.
Communicate daily regarding large cases to the appropriate individuals.
Services telephone inquiries, internal and external, for status questions and for questions regarding claims.
Performs other job-related duties that may be occasionally assigned.