Nationwide is hiring a Medical Claims Consulting Specialist in Lone Tree, CO. Qualified Candidates MUST HAVE 5+ years of nursing experience, a strong medical background, and outstanding skills in teaching and communication (both oral and written).
JOB SUMMARY: Provides medical consultation, support, and claim file intervention for claims partners. Consulting includes areas such as life expectancy, reasonableness and appropriateness of treatment, medical or vocational cost projection, anticipated treatment needs over the life of the injured claimant, and may include direct contact with healthcare providers. Responsible for creating, coordinating, facilitating and/or implementing medical training programs. May interact, coordinate or manage vendor programs and relationships. Manages cost containment, risk mitigation and regulatory compliance issues relative to medical claims.
RELATIONSHIP: Reports to Manager or Director. No direct reports.
1. Participates in and attends suit file conferences, alternative dispute resolution sessions and medical depositions.
2. Prepares claims staff and defense counsel for discovery processes, alternative dispute resolution, and suit file/trial strategy as related to case-specific medical issues.
3. Presents medical training to claims staff (including claims managers, claims representatives, legal, and special investigative unit) and defense counsel/trial division as directed and prepared by corporate medical management.
4. Provides medical bill audit expertise and supports medical cost containment programs in accordance with corporate and state directives.
5. Supports claim reps in face to face meetings with claimants and/or attorneys to expedite negotiations and settlements.
6. Participates in open and closed file reviews related to medical skill building opportunities for the claims staff.
7. Works with Claims and special investigative unit to identify, investigate, and prosecute medical fraud.
8. Participates in roundtables and file conferences at the request of the claims manager.
9. Supports the claim manager in the Independent Medical Exam/Peer Review process and monitors quality of associated vendors.
10. Completes complex injury file reviews at the direction of the claims manager.
11. Supports corporate guidance and direction related to medical specialist best practices.
12. Performs other duties as assigned.
Education: College degree in Nursing, business, insurance or medical related field preferred. RN or CCM preferred.
Experience: 5 years in medical profession and/or claims experience preferred.
Knowledge: Broad-based medical knowledge. Knowledge of medical and legal issues pertaining to property and casualty claims processes and practices including common treatment protocols, medical billing practices and bill review, and alternative dispute resolution and litigation processes.
Skills: Ability to investigate and credibly contradict erroneous or exaggerated assertions regarding medical conditions and their relatedness. Ability to negotiate with attorneys and medical providers. Oral presentation skills pertinent to training and legal environments. Effective written communication with special attention to spelling, grammar, and technical terminology suitable for internal and external review. Ability to set work priorities and work in a consulting role. Proficient with personal computer skills, word processing, spreadsheet, and graphical presentation software.
Values: Regularly and consistently demonstrates the Nationwide Values and Guiding Behaviors.
Staffing Exceptions to the above minimum job requirements must be approved by the:
Overtime Eligibility: Not Eligible
Working Conditions: Normal office environment. Frequent lifting of medical file boxes.
ADA: The above statements cover what are generally believed to be principal and essential functions of this job. Specific circumstances may allow or require some people assigned to the job to perform a somewhat different combination of duties.
Job Evaluation Activity: 8/2012: CB
Job Function/Family: CLM/MED
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