Claims Clinical Specialist - Medical Review Team

Genworth Financial

4d • Hybrid

About The Position

As an Operations team member, you will play a crucial role in delivering world class customer service and capabilities to our policyholders – now and in the future. The Clinical Specialist is an excellent opportunity for a Registered Nurse or Licensed Social Worker. Bring your clinical knowledge and experience, and Genworth will provide the training necessary to succeed in this role. You will be responsible for improving our in-house certification functions by providing updates to the plan of care, in-house certifications, completing telephonic assessments, and monitoring claimants with multiple health conditions. This position will promote the provision of evidence-based, short-term case management services to long-term care insurance policyholders.

You will identify process improvement opportunities, provide feedback on processes and case management model as well as be a critical team member in enhancing the team’s performance and results. You will be responsible for communicating with medical personnel at Long Term Care Facilities by conducting telephonic assessments for claimants to develop the plan of care and provide tax qualified certifications as required by the policy. You will be responsible for obtaining information about the medical status and care needs of the insured to best understand disease progression, ADL/IADL loss and cognitive status. You will be responsible for making decisions about the care need expectations and benefit eligibility of the insured as it aligns with specific policy requirements and the HIPAA regulations related to Tax Qualification Certification. You will be responsible for identifying, requesting, and analyzing pertinent medical records required to best understand the disease progression, ADL/IADL loss and potential for recovery. You will be responsible for working within a structured environment with established Standard Operating Procedures to ensure consistency of claims practices. You will identify process improvement opportunities, provide feedback on processes and case management model as well as be a critical team member in enhancing the team’s performance and results. You will be responsible for communication, teamwork and collaboration, and partnering with other teams or departments to achieve common goals and support continuous improvement initiatives.

Requirements

• Active Licensed Social Worker or Registered Nurse
• At least two years-experience working in a role that required an understanding of single and cumulative medical conditions (particularly those common in the aging process), including their effect on physical/cognitive function, as well as their prognosis and rehabilitative potential.
• Able to understand and interpret MDS, Plan of Care, Physician Records and Occupational/Physical Therapist records and understand disease progression and recovery expectations.
• Demonstrated experience in making sound business decisions using risk management and quality protocols.
• Able to manage and prioritize work queues and multiple job responsibilities.
• Consistent, reliable, and predictable attendance to support the needs of the business.
• Ability to understand and interpret insurance contracts and Long-Term Care benefits.
• Good working knowledge of systems applications (e.g., WORD, EXCEL, PowerPoint, etc.)

Responsibilities

• Improving in-house certification functions by providing updates to the plan of care and in-house certifications.
• Completing telephonic assessments.
• Monitoring claimants with multiple health conditions.
• Promoting the provision of evidence-based, short-term case management services to long-term care insurance policyholders.
• Identifying process improvement opportunities and providing feedback on processes and case management model.
• Enhancing the team’s performance and results.
• Communicating with medical personnel at Long Term Care Facilities by conducting telephonic assessments for claimants to develop the plan of care.
• Providing tax qualified certifications as required by the policy.
• Obtaining information about the medical status and care needs of the insured to best understand disease progression, ADL/IADL loss and cognitive status.
• Making decisions about the care need expectations and benefit eligibility of the insured as it aligns with specific policy requirements and HIPAA regulations related to Tax Qualification Certification.
• Identifying, requesting, and analyzing pertinent medical records required to best understand disease progression, ADL/IADL loss and potential for recovery.
• Working within a structured environment with established Standard Operating Procedures to ensure consistency of claims practices.
• Communication, teamwork and collaboration, and partnering with other teams or departments to achieve common goals and support continuous improvement initiatives.

Benefits

• Competitive Compensation & Total Rewards Incentives
• Comprehensive Healthcare Coverage
• Multiple 401(k) Savings Plan Options
• Auto Enrollment in Employer-Directed Retirement Account Feature (100% employer-funded!)
• Generous Paid Time Off – Including 12 Paid Holidays, Volunteer Time Off and Paid Family Leave
• Disability, Life, and Long Term Care Insurance
• Tuition Reimbursement, Student Loan Repayment and Training & Certification Support
• Wellness support including gym membership reimbursement and Employee Assistance Program resources (work/life support, financial & legal management)
• Caregiver and Mental Health Support Services

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed