The Claims Support Nurse provides medical information, support, advice, and training to Claims Professionals and other Claims staff.
ESSENTIAL RESPONSIBILITIES AND PRINCIPAL ACCOUNTABILITIES:
- Provide information, alerts, support, and advice to Claims Professionals and others regarding medical issues in claims including causation, diagnosis, prognosis, and the appropriateness and effectiveness of treatment either upon the request of the Claims Professional or pursuant to a program in which claims that meet specified criteria are reviewed by the Claims Support Nurse
- Develop cost projections for use in reserving and settlement analysis, seeking input and support from Medical Bill Review and Utilization Review as appropriate, to help identify the likelihood and cost of possible future treatment, and upon request participate in roundtable discussions regarding those valuations.
- Participate in strategic planning meetings regarding major claims, providing guidance and advice on the medical issues in the claims.
- Coordinate with Utilization Review and Claims Professionals to help monitor and guide the medical treatment provided to injured workers.
- Support Claims Professionals in ensuring that field case nurses are assigned in appropriate claims in a timely manner, are given clear assignments, perform their work effectively and efficiently, and are removed from claims when their services are no longer required.
- Upon request, prepare and present training to Claims staff on medical topics.
- Assess and record the quality of services provided by medical providers in order to help support the creation and continued improvement of high-quality provider panels and networks.
- Foster a positive and close working relationship with other Company staff, including the adjusting staff, utilization review, medical bill review, special investigations, legal, and lien resolution.
- Maintain patient confidentiality and safeguard protected health information in accordance with state and federal laws and Company policies.
- Attain and maintain a high level of current medical knowledge relating to the injuries and conditions most common in workers compensation claims, including new methods of diagnosis and treatment, as well as the treatment guidelines and other medical authorities relevant to the jurisdictions within their responsibilities.
- Ethics: Demonstrates sound personal and professional character including candor, honesty, professional behavior, and a positive attitude. Promptly brings any errors, adverse results, or other issues of concern to the attention of the supervisor.
- Judgment: Displays confidence and willingness to make difficult decisions. Exhibits sound and accurate judgment. Supports and explains reasoning for decisions. Includes appropriate people in decision-making process. Makes timely decisions.
- Customer Relations: Provides effective communication with customers. Appropriately responds to and resolves complex situations or problems. Responds promptly to customer inquiries. Meets commitments.
- Problem Solving: Gathers and analyzes information skillfully and provides solutions in complex situations. Identifies items requiring additional information or action.
- Quality: Demonstrates accuracy and thoroughness when performing work processes. Applies feedback to improve performance. Monitors own work to ensure quality.
- Quantity: Meets productivity standards. Completes work in a timely manner. Strives to increase productivity. Works quickly.
- Written Communication: Prepares clear written text on complex technical matters in terms that will be understood by the recipient of the document.
- Oral Communication: Speaks clearly when explaining complex technical matters. Asks questions freely to broaden knowledge and skills. Listens and gets clarification. Responds well to questions. Participates in meetings in an open and interactive manner.
- Professionalism: Approaches others in a tactful manner. Reacts well under pressure. Treats others with respect and consideration regardless of their status or position. Accepts responsibility for own actions. Follows through on commitments.
- Certification and Education: Bachelor of Science Nursing degree (BSN); or Registered Nursing degree (RN), or Associate Nursing degree - Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN); with an active license.
- Language Ability: Able to read, analyze, and interpret medical journals, statutes, regulations, medical reports, medical coding, medical bills, claim notes, claim data fields, financial reports, and legal documents. Able to respond to technical inquiries from Company employees, external sources, and regulatory or auditing entities.
- Math Ability: Able to calculate figures and amounts such as discounts, interest, proportions, percentages, sums, differences, products, and volumes.
- Reasoning Ability: Able to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Able to deal with problems involving several concrete variables in standardized situations.
- Technical Skills: Knowledge of current recognized evidence based medicine guidelines, office operations, workflow analysis, and current technologies in telecommunications, data entry, and file management.
- Computer Skills: Knowledge of Microsoft Office software. Able to quickly master proprietary and vended software applications.