Mutual of Omaha Clinical Nurse Consultant (Individual Claims) - Omaha, NE in LAVISTA, Nebraska
Reviews, analyzes, and interprets medical information associated to claims. Completes a thorough evaluation of all of the medical information that is available to determine restrictions and limitations, and provides consulting on return to work and recovery opportunities. Facilitates educational opportunities for the Claims staff and provides clinical subject matter expertise for business partners. Monitors vendor services for quality and cost, and reports results and/or recommendations to management.
Essential Job Functions:
Provides consultative services to include analyzing and interpreting medical information on claims. Assesses medical information for adequacy and consistency. Obtains and clarifies medical information and interprets medical reports. Arranges the relevant material into facts, considers uniqueness of claim in order to document opinions. Identifies medical restrictions and limitations. Provides expected durations for recovery, and recommendations for next steps. Monitors the quality of care, investigates alternate care options, costs, and outcomes.
Orders and monitors vendor services for disability case management or long term care assessments. Reports on successful vendor relationships and related savings. Develops and maintains nation-wide database of available services and resources.
Maintains effective communication with policyholders and their families or representatives, doctors, medical facilities, attorneys, insurance companies, providers, employers, the sales force, and social/investigative/care assessment/case management agencies to compile information for approval or denial of claim. Communicates with claimants in clarifying policy benefits and/or developing a care plan.
Provides clarification for Independent Medical Exam IMEs, medical records, lab results, office notes, MRIs(Magnetic Resonance Imaging), BEAs etc.
Remains abreast of the dynamic and competitive insurance environment. Participates in Industry or Association meetings and seminars focusing case management for long term care or disability issues.
Makes recommendations on the appropriateness in the coordination of external medical consultations when applicable. Keeps management informed on the quality of these services and resources and maintains appropriate risk strategies.
Establishes effective communication with medical facilities and providers. Effectively informs attending physicians and other treating sources about restrictions and limitations, work capacity, and initiates discussions with attending physician regarding complex medical conditions and seeks clarification from attending physician when necessary.
Assists the Law Division on lawsuits including participation in claim depositions or trials.
Utilizes clinical background and experience to determine appropriate medical handling techniques focusing on case management.
Develops and facilitates training programs and presentations designed to educate the claim associates on medical issues or issues surrounding claims.
Researches and develops innovative alternative care programs and strategies designed to provide value added services, minimize risks and control costs.
This position requires up to 33% travel, which may include flying and/or driving and some overnight stays.
This position requires sitting over 66% of the time.
This position requires Visual Acuity at 20 inches (or less) over 66% of the time.
- Licensed Registered Nurse with knowledge or experience in assigned area, which should include at least one of the following: disability case management, elder care issues, long term care, critical illness, early intervention concepts, treatment mechanisms,
claim procedures and computer systems.
Sound judgement, high level of initiative and creativity, proven analytical and problem solving skills; strong and confident decision making abilities.
Strong oral and written communication, interpersonal facilitation and organizational skills.
Ability to work in a fast paced, team based, corporate environment. Willingness and the ability to learn and adapt to an ever-changing work environment.
Ability to travel up to 25% of work period
Ability to type and maneuver through multiple office and business systems.
Willingness and the ability to learn additional insurance products and procedures as needed.
Bachelor of Science degree preferred but will consider Associate Degree with additional credentials or work experience in related fields.
Ability to work autonomously, apply critical thinking, creates concise and sound conclusions, meets deadlines and manages case/workload.
Remains aware of the impact to the customer while continuing to be compliant and exhibiting a sense of urgency with a high level of quality in the management of cases and decisions.
Knowledge of and experience with policy language and provisions as well as Regulatory environment ( i.e., ERISA).
- Bachelor's Science Nursing (BSN) is preferred
If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact a Human Resources Representative at 1-800-780-0304. We are available Monday through Friday 7 am to 4:30 pm CST.
For all other inquiries, contact our HR Helpline at 1-800-365-1405.
Mutual of Omaha and its affiliates are an Equal Opportunity /Affirmative Action Employer, Minorities/Female/Disabled/Veteran
To All Recruitment Agencies: We do not accept unsolicited agency resumes and we are not responsible for any fees related to unsolicited resumes.