Clinical Nurse Specialist

RSLI; United States; Hybrid; USD 67,000 - 96,000; Full time

Job summary

Reliance Matrix in the United States is seeking a Clinical Nurse Specialist to review medical documentation in claim files and coordinate independent medical examinations, peer reviews, and functional capacity evaluations.

The role involves determining appropriate questions to address, presenting files to physicians for review, performing case management, and serving as a resource for examiners with disease/medical condition references. Travel up to 10% could be required.

Qualifications

• BSN degree preferred and RN licensure current in the state.
• Minimum of three (3) years of related experience.
• Strong clinical, case management and behavioral health experience preferred.
• Experience with processing insurance claims and long-term disability claims is preferred.
• Excellent written and verbal communication in a public-facing environment.

Responsibilities

• Reviews all medical documentation in claim files to answer questions posed by claims examiners and managers.
• Coordinates and monitors independent medical examinations, peer reviews and functional capacity evaluations.
• Determines whether questions can be addressed; refer or explain as needed.
• Ensures appropriate files are presented to physicians or specialists for review.
• Performs case management responsibilities as required.
• Serves as a resource for examiners and provides disease/condition references.
• Participates in training and may testify in legal proceedings.
• Maintains monthly metrics tracking of designated activities.

Skills

Clinical nursing

Case management

Verbal communication

Written communication

Insurance claims processing

MS Office

Travel willingness

Education

RN licensure

BSN degree preferred

Tools

Microsoft Word

Microsoft Excel

Job description

Job Responsibilities and Responsibilities

KEY RESPONSIBILITIES

• other duties as assigned

Job Summary :

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 Clinical Nurse Specialist . If not, refer the file to the appropriate member of the Technical Support team or return the file with a complete explanation.
• 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.
• Serves as a resource for examiners and consults with them about medical issues as necessary and provides reference information on the disease/ medical conditions where appropriate.
• Assists with training of Claims Department personnel as requested by management, and provides feedback regarding training opportunities (Huddles, Lunch & Learns, team meetings, etc.).
• Participates in sales presentations as requested.
• Schedules and monitors independent medical examinations, peer reviews and functional capacity evaluations.
• 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.
• Participates in Claims Discussion Meetings (CDM's) with claims examiners and supervisors to review and discuss complex claims.
• Maintains monthly metrics tracking of designated activities.
• All other duties as assigned.

REQUIRED KNOWLEDGE, SKILLS, ABILITIES, COMPETENCIES, AND/OR RELATED EXPERIENCE

• or equivalent experience gained from any combination of formal education, on-the-job training, and/or work and life experience
• BSN degree preferred.
• Minimum of three (3) years of related experience.
• Registered Nurse with current state licensure.
• Strong clinical, case management and behavioral health experience preferred.
• Experience with the processing of insurance claims required. Experience with the handling of long-term disability claims or integrated disability claims preferred.
• 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. Microsoft Office, (including Word and Excel), telephone, fax machine, calculator.
• Prior experience using an automated claim system desirable.
• Some travel may be required.

Ability to Travel

Up to 10%

PHYSICAL REQUIREMENTS

When used in the description below, the following terms are defined as:

• "Occasional": done only from time to time, but necessary when it is performed
• "Frequent": regularly performed; generally an act that is required on a daily basis
• "Continuous": typically performed for the majority of an employee's shift

Sitting for prolonged periods of time, frequently standing, walking distances up to one mile, bending, crouching, kneeling, reaching, occasionally lifting 25lbs, extensive typing, picking up and holding small objecting and otherwise using primarily the fingers rather than the entire hand. Employee is required to have visual acuity sufficient to perform activities such as preparing and analyzing data and figures; transcribing notes; viewing a computer terminal and extensive reading. Employee is required to have hearing sufficient to understand verbal instruction and answer telephones. Reliance Matrix will provide qualified employees with a reasonable accommodation in accordance with applicable law.

CORE VALUES

• Collaboration
• Compassion
• Empowerment
• Integrity
• Fun

The above description reflects the general details considered necessary to describe the principle responsibilities and functions of the job identified and shall not be construed as a detailed description of all the work requirements that may be inherent to this job.

The expected hiring range for this position is $66,660.00 - $96,100.00 annually. This expected hiring range covers only base pay and excludes any other compensation components such as commissions or incentive awards. The successful candidate's starting base pay will be based on several factors including work location, job-related skills, experience, qualifications, and market conditions. These ranges may be modified in the future.

Work location may be flexible if approved by the Company.

What We Offer

At Reliance Matrix, we believe that fostering an inclusive culture allows us to realize more of our potential. And we can't do this without our most important asset-you.

That is wh