The Rehabilitation Nurse reviews all medical (and other) documentation in claim files to answer the specific questions posed by claims examiners and managers. Coordinates and monitors independent medical examinations, peer reviews and functional capacity evaluations.
Duties and Responsibilities:
Determines whether questions posed by claims examiners and/or management can be appropriately addressed by the Rehabilitation Nurse. If not, refer the file to the appropriate member Ensures that appropriate files are presented to physicians and/or specialists for review.
Reviews and evaluates the medical (and other) records contained within the claim file and responds to the specific question(s) posed by the claims examiner or manager.
Performs case management responsibilities as required.
Provides reference information on the sickness or disease generally where appropriate.
Serves as a resource for examiners and consults with them about medical issues as necessary.
Recommends appropriate resource materials for purchase.
Assists with training of Claims Department personnel as requested by management, and provides feedback regarding training opportunities.
Participates in sales presentations as requested. Some travel may be required.
Schedules and monitors independent medical examinations, peer reviews and functional capacity evaluations.
Monitors the quality, efficiency and cost-effectiveness of vendors providing these services and makes appropriate recommendations.
May work with affiliated companies to achieve corporate results.
Suggests improvements to processes, procedures and products as appropriate.
May testify as necessary in legal proceedings.
All other duties as assigned.
Education, Qualifications and Experience:
BSN degree required.
Minimum of three (3) years of related experience.
Registered Nurse with current state licensure.
Strong clinical or case management background desirable.
Experience with the processing of insurance claims desirable. Experience with the handling of long-term disability claims or integrated disability claims helpful.
Proven ability to work well in a high visibility, public oriented environment, with excellent written and verbal communication skills.
Proven ability to work with the following equipment: P.C.(including Word and Excel), telephone, fax machine, calculator.
Prior experience using an automated claim system desirable.