Nurse Case Manager - Specialist, Medical Claims Consultant
Location: Harleysville, Pennsylvania
Description: Harleysville Insurance is at present recruited Nurse Case Manager - Specialist, Medical Claims Consultant right now, this career will be dwelled in Pennsylvania. For detail informations about this career opportunity kindly see the descriptions. This role is specific to nurse case management where the primary objective is to assist the Workers’ Compe! nsation and No-Fault claim departments with medical oversight and possible case management of an injured party’s claim. This will be achieved through the collaborative process of injury assessment, medical planning, facilitation and coordination of care with the injured party and claim units in order to promote cost-effective outcomes. For workers’ compensation claims, the nurse case manager will also assist the policyholder, claim department and injured worker in the facilitation of an early return to work by evaluating the existing job descriptions. In regards to no-fault claims, the nurse case manager may assist the injured party with coordination of care and the claim department with high level medical oversight and case file reviews. The above will be achieved by a multitude of means such as case file reviews, telephonic case management, onsite case management and will reside in our Harleysville, PA location. QUALIFICATIONS Ø Education/Credentials: BSN (Bachelor D! egree in Nursing) OR (RN with a Bachelor Degree ) and CCM Cert! ified Case Manager. Additional state licensures a plus. Ø Experience: Five to seven years of clinical nursing experience in addition to direct insurance industry experience, i.e. telephonic case management and/or on-site medical case management required. Additional experience in catastrophic case management a plus. Ø Exposure to Workers Compensation and Personal Injury Protection claims is preferred. Experience in insurance industry preferred as well as industry education such as Intro Claims, Intro to Insurance, AIC 34 Ø Must be available to travel for potential training opportunities within our claim departments as well as medical appointments for injured party’s that occur within a radius of the Harleysville, PA office (Physician appointments could occur in the local PA, NJ and DE areas). JOB SUMMARY: Provides medical consultation, support, and claim file intervention for claims partners. Consulting includes areas such as life expectancy, reasonableness and appropri! ateness of treatment, medical or vocational cost projection, anticipated treatment needs over the life of the injured claimant, and may include direct contact with healthcare providers. Responsible for creating, coordinating, facilitating and/or implementing medical training programs. May interact, coordinate or manage vendor programs and relationships. Manages cost containment, risk mitigation and regulatory compliance issues relative to medical claims.
RELATIONSHIP: Reports to Manager or Director. No direct reports.
JOB RESPONSIBILITIES:
1. Participates in and attends suit file conferences, alternative dispute resolution sessions and medical depositions.
2. Prepares claims staff and defense counsel for discovery processes, alternative dispute resolution, and suit file/trial strategy as related to case-specific medical issues.
3. Presents medical training to claims staff (including claims managers, claims representatives, legal, ! and special investigative unit) and defense counsel/trial division as d! irected and prepared by corporate medical management.
4. Provides medical bill audit expertise and supports medical cost containment programs in accordance with corporate and state directives.
5. Supports claim reps in face to face meetings with claimants and/or attorneys to expedite negotiations and settlements.
6. Participates in open and closed file reviews related to medical skill building opportunities for the claims staff.
7. Works with Claims and special investigative unit to identify, investigate, and prosecute medical fraud.
8. Participates in roundtables and file conferences at the request of the claims manager.
9. Supports the claim manager in the Independent Medical Exam/Peer Review process and monitors quality of associated vendors.
10. Completes complex injury file reviews at the direction of the claims manager.
11. Supports corporate guidance and direction related to medical specialist best practices.
12. Performs other dut! ies as assigned.
JOB REQUIREMENTS :
Education: College degree in Nursing, business, insurance or medical related field preferred. RN or CCM preferred.
Experience: 5 years in medical profession and/or claims experience preferred.
Knowledge: Broad-based medical knowledge. Knowledge of medical and legal issues pertaining to property and casualty claims processes and practices including common treatment protocols, medical billing practices and bill review, and alternative dispute resolution and litigation processes.
Skills: Ability to investigate and credibly contradict erroneous or exaggerated assertions regarding medical conditions and their relatedness. Ability to negotiate with attorneys and medical providers. Oral presentation skills pertinent to training and legal environments. Effective written communication with special attention to spelling, grammar, and technical terminology suitable for intern! al and external review. Ability to set work priorities and work in a co! nsulting role. Proficient with personal computer skills, word processing, spreadsheet, and graphical presentation software.
Values: Regularly and consistently demonstrates the Nationwide Values and Guiding Behaviors .
Staffing Exceptions to the above minimum job requirements must be approved by the:
JOB CONDITIONS:
Overtime Eligibility: Not Eligible
Working Conditions: Normal office environment. Frequent lifting of medical file boxes.
ADA : The above statements cover what are generally believed to be principal and essential functions of this job. Specific circumstances may allow or require some people assigned to the job to perform a somewhat different combination of duties.
Job Evaluation Activity: 8/2012: CB
Job Function/Family: CLM/MED
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If you were eligible to this career, please send us your resume, with salary requirements and a resume to Harleysville In! surance.
Interested on this career, just click on the Apply button, you will be redirected to the official website
This career will be started on: Wed, 22 May 2013 16:06:08 GMT
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