Clinical Nurse Specialist
About The Position
The Clinical Nurse Specialist reviews medical and other documentation in claim files to answer questions from claims examiners and managers. The role coordinates and monitors independent medical examinations, peer reviews, and functional capacity evaluations, and performs case management responsibilities as required. It also serves as a medical resource for claims examiners, supports staff training, may participate in sales presentations and legal proceedings, and contributes to improvements in processes, procedures, and products. The position may work with affiliated companies and participates in Claims Discussion Meetings to review complex claims. The role maintains monthly metrics for designated activities. Work location may be flexible if approved by the Company. Some travel may be required, up to 10%.
Requirements
- Registered Nurse with current state licensure.
- Minimum of three years of related experience.
- Experience processing insurance claims.
- Strong written and verbal communication skills and ability to work effectively in a high-visibility, public-oriented environment.
- Ability to use a PC and Microsoft Office, including Word and Excel, as well as a telephone, fax machine, and calculator.
- Ability to travel up to 10%.
- Ability to perform the physical requirements described, including prolonged sitting, frequent standing and walking, bending, crouching, kneeling, reaching, occasional lifting up to 25 pounds, extensive typing, and handling small objects.
- Visual acuity sufficient for preparing and analyzing data and figures, transcribing notes, viewing a computer terminal, and extensive reading.
- Hearing sufficient to understand verbal instructions and answer telephones.
Nice To Haves
- BSN degree preferred.
- Strong clinical, case management, and behavioral health experience preferred.
- Experience handling long-term disability claims or integrated disability claims preferred.
- Prior experience using an automated claim system is desirable.
Responsibilities
- Determine whether questions from claims examiners or management can be addressed by the Clinical Nurse Specialist; refer questions to the appropriate Technical Support team member or return the file with an explanation when necessary.
- Ensure appropriate files are presented to physicians or specialists for review.
- Review and evaluate medical and other records in claim files and respond to questions from claims examiners or managers.
- Perform case management responsibilities as required.
- Serve as a resource for examiners, consult on medical issues, and provide reference information on diseases or medical conditions when appropriate.
- Assist with training Claims Department personnel as requested and provide feedback on training opportunities.
- Participate in sales presentations as requested.
- Schedule and monitor independent medical examinations, peer reviews, and functional capacity evaluations.
- Work with affiliated companies to achieve corporate results, as needed.
- Suggest improvements to processes, procedures, and products.
- Testify in legal proceedings as necessary.
- Participate in Claims Discussion Meetings with claims examiners and supervisors to review and discuss complex claims.
- Maintain monthly metrics tracking for designated activities.
- Perform other duties as assigned.
Benefits
- Annual performance bonus for all team members.
- Generous 401(k) company match that is immediately vested.
- Choice of three medical plans, including prescription drug coverage; company contribution to a Health Savings Account for High Deductible Health Plan enrollees.
- Multiple options for dental and vision coverage.
- Company-provided life and disability insurance.
- Paid parental leave and adoption assistance.
- Hybrid work arrangements for eligible roles.
- Tuition reimbursement and continuing professional education.
- At least 20 days of paid time off per year for new hires, in addition to nine company-paid holidays; PTO may increase based on company level and years of service.
- Volunteer days, community partnerships, and an Employee Assistance Program.
- Employee Resource Group program.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
