Case Manager

ullico inc.; Bethesda (MD); On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Health/Dental/Vision

Pension

401K

Health Savings Account

Life Insurance

Paid Time Off

Job summary

Ullico Inc. is actively recruiting a Case Manager for the Silver Spring, MD office. The role involves analyzing claims for potential financial exposure, gathering clinical information, and providing recommendations. Ideal candidates will possess a BSN and RN license with at least 5 years of clinical experience.

Benefits include health insurance, a pension plan, and a 401K. The company has been a proud partner of the labor movement for over 95 years, ensuring protection for its customers.

Qualifications

• Five plus years of significant clinical experience.
• Minimum of 5 years of clinical experience required.
• Knowledge of HIPAA regulations.

Responsibilities

• Analyze reports to identify potential financial exposure early in claims.
• Gather clinical information from providers for cost containment.
• Compose clinical correspondence and communicate with stakeholders.

Skills

Clinical experience

Customer service skills

Communication skills

Multi-tasking

Education

Bachelor of Science in Nursing (BSN) or higher

Active RN license or APRN license

Tools

PC

Microsoft Word

Microsoft Excel

Connexure ESL platform

Job description

Union Labor Life Insurance Company is actively recruiting a Case Manager for our Silver Spring, MD office.

Responsibilities

• Analyze “trigger reports” and high dollar claim referrals to identify potential financial exposure early in the claims process. Review the medical necessity and appropriateness of hospital claims, physician charges, specialty drug costs, usage and provide potential alternatives.
• Gather and analyze clinical information and medical records from all providers for cost containment and future cost determination by maintaining a close working relationship with plan administrators, vendors, third party payers, employers, re-insurers, and other social, psychological, and medical health care providers.
• Translate complex clinical information from medical reference books, patient medical records, charges, summary plan descriptions, and stop loss insurance benefits into clear, actionable reporting to evaluate liability/compensability and to make recommendations to non-clinical stakeholders.
• Compose clinical correspondence and communicate effectively with employees, employers (clients), TPA claims administrators, health care providers, claims and underwriting staff and executive management regarding current care and care alternatives.
• Apply clinical knowledge to make determinations of medical necessity. Troubleshoot complex clinical problems and practice independently without supervision of another licensed professional.
• Assess medical needs, care requirements and alternatives; monitor and follow up with the Plan Administrator, provider, etc. regarding the planning, coordination and progress of treatment; evaluate and suggest other treatment and facility alternatives as appropriate to facilitate quality, cost-effective medical care for high-risk individuals, trigger diagnoses and transplant losses.
• Provide cost containment by managing an inventory of Stop Loss claims (involving large case management, trigger diagnosis or transplant network losses), securing additional discounts from providers (either directly or through a preferred vendor), negotiating prices for medical services and supplies, negotiating settlements, developing transplant networks, evaluating losses, consulting with claims examiners about appropriateness of charges and educating clients and stop loss team about cost-effective alternatives.
• Work closely with Underwriting, Actuarial, Finance and other areas of the organization to provide clinical insights that inform policy pricing and reserve setting. Evaluate group claim information at the time of renewal and new business and provide underwriters with an estimated projection of expected claim dollars in the next policy period.
• Prepare monthly report on all large case management. Communicate daily regarding large cases to the appropriate individuals.
• Services telephone inquiries, internal and external, for status questions and for questions regarding claims. External/internal calls can and/or may be recorded and retained electronically specific to the department’s scope of services.
• Performs other job-related duties that may be occasionally assigned.

Qualifications

• Bachelor of Science in Nursing (BSN) or higher.
• Active RN license or APRN license.
• Five plus years of significant clinical experience, with backgrounds in acute or critical care being highly valued. Minimum of 5 years of clinical experience required; experience in acute or critical care strongly preferred.
• Broad range of HIPAA regulations required.
• Knowledge and hands‑on experience with PC; Word, Excel required. Familiarity with Connexure ESL platform a plus.
• Demonstrated customer service skills.
• Demonstrated oral and written communication skills with all levels of personnel.
• Demonstrated ability in multi‑tasking.

Benefits

• Health/Dental/Vision
• Pension
• 401K
• Health Savings Account
• Life Insurance
• Paid Time Off

Ullico is an Equal Opportunity Employer. This organization participates in E-Verify.

For over 95 years, Ullico, the only labor‑owned insurance and investment company, has been a proud partner of the labor movement. From insurance products for members, leaders and employers, to investments that have created thousands of union jobs, our customers continue to count on Ullico to protect them. The Ullico Inc. family of companies includes The Union Labor Life Insurance Company; Ullico Casualty Group, Inc.; Ullico Investment Company, Inc.; and Ullico Investment Advisors, Inc. Visit www.ullico.com.