Clinical Claim Management Accuracy

ABOUT GUARDIAN

Every day, Guardian gives 26 million Americans the security they deserve through our insurance and wealth management products and services. Since our founding in 1860, our long-term view has helped our customers prepare for whatever life brings whether starting a family, planning for the future or taking care of employees. Today, we’re a Fortune 250 mutual company and a leading provider of life, disability and other benefits for individuals, at the workplace and through government sponsored programs. The Guardian community of ~9000 employees and our network of over 2750 financial representatives is committed to serving with expertise when, where and how our clients need us. Our commitments rest on a strong financial foundation, which at year-end 2017 included $8.0 billion in capital and $1.6 billion in operating income. For more information, please visit guardianlife.com or follow us on Facebook, LinkedIn, Twitter and YouTube. 

Guardian is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age, race, color, creed, religion, sex, affectional or sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.

Guardian® is a registered trademark of the Guardian Life Insurance Company of America.

POSITION SUMMARY

The Clinical Claim Management Accuracy (CMA) Consultant is responsible for the execution of the CMA program within Guardian’s Disability Clinical and Vocational Service team.  The Clinical CMA plays a critical role in ensuring the integrity and excellence of clinical reviews conducted by our Clinicians. This individual is responsible for evaluating the quality of the clinical assessments and recommendations, identifying performance trends and gaps, and recommending actionable solutions to enhance team effectiveness and outcomes.

CANDIDATE RESPONSIBILITIES

Key Responsibilities:

• Quality Assessment & Feedback
  • Conduct thorough reviews of clinical claim assessments to ensure accuracy, consistency, and well-supported rationale.
  • Reviews will evaluate proficiencies in information gathering, resource utilization, ongoing case management, documentation and risk management.   
  • Perform calibration discussions with Seniors and People Leaders
  • Deliver clear, concise, constructive, and timely feedback to our clinicians to support continuous improvement.
• Performance Analysis & Improvement
  • Identify trends, recurring issues, and potential root causes in clinical review quality.
  • Collaborate with leadership to develop and implement solutions that address performance gaps and elevate team standards.
  • Assist people leaders in upskilling the individual/team
  • Provide an analysis of team and individual performance highlighting findings and improvement recommendations.
• Cross-Functional Support
  • Participate in ad hoc audits, projects, and initiatives as needed.
  • Provide clinical expertise on complex clinical discussions such as Vendor Referral Discussions
  • Flex into clinical review responsibilities during peak periods or staffing needs.
  • Provides oversight for our Vendor Management Program; invoice management,  vendor management, vendor tracking, quality and feedback for our vendors,

REPORTING RELATIONSHIPS

This position reports to the Head of Clinical and Vocational Services who, in turn, reports to the Head of Shared Services, Group Claims.

CANDIDATE QUALIFICATIONS

Functional Skills

• Excellent verbal and written communication skills
• Strong analytical, organizational, time management and problem solving skills
• Ability to prioritize and manage multiple tasks in a fast-paced environment
• Proven training skills on an individual and team basis
• Ability to mentor/coach staff and peers to ensure proper claim adjudication and contribute to staff development
• Ability to work independently and within a team
• Demonstrated ability to identify and manage risk
• Self-motivated
• Extensive knowledge of Group Long-term disability product, administration, and clinical procedures
• Strong knowledge of PC Applications (including Microsoft Office, databases, imaging systems,  etc.)
• Superior working knowledge of the medical and investigative aspects of clinical disability claims management
• Excellent PC skills with knowledge of MS Word/Excel/PPT

Leadership Behaviors:

• Continuously strives to provide superior customer service
• Expresses oneself in an open and honest manner
• Demonstrates self-awareness and embraces feedback

Position Qualifications:

• Registered Nurse (RN) with active license required.
• 3+ years clinical claims review experience, prior DI experience or equivalent experience required
• Minimum 1 year experience providing feedback to front line staff and frontline supervisors
• Prior experience with STD, LTD, and/or Appeals a plus
• Prior experience review BH claims
• Prior experience in a quality assurance role a plus
• Prior people manager experience a plus

Travel

As needed, but not typically required

Salary Range:

The salary range reflected above is a good faith estimate of base pay for the primary location of the position. The salary for this position ultimately will be determined based on the education, experience, knowledge, and abilities of the successful candidate. In addition to salary, this role may also be eligible for annual, sales, or other incentive compensation.

Our Promise

At Guardian, you’ll have the support and flexibility to achieve your professional and personal goals.  Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.

Inspire Well-Being

As part of Guardian’s Purpose – to inspire well-being – we are committed to offering contemporary, supportive, flexible, and inclusive benefits and resources to our colleagues. Explore our company benefits at www.guardianlife.com/careers/corporate/benefits. Benefits apply to full-time eligible employees. Interns are not eligible for most Company benefits.

Equal Employment Opportunity

Guardian is an equal opportunity employer. All qualified applicants will be considered for employment without regard to age, race, color, creed, religion, sex, affectional or sexual orientation, national origin, ancestry, marital status, disability, military or veteran status, or any other classification protected by applicable law.

Accommodations

Guardian is committed to providing access, equal opportunity and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities. Guardian also provides reasonable accommodations to qualified job applicants (and employees) to accommodate the individual's known limitations related to pregnancy, childbirth, or related medical conditions, unless doing so would create an undue hardship. If reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact MyHR@glic.com. Please note: this resource is for accommodation requests only. For all other inquires related to your application and careers at Guardian, refer to the Guardian Careers site.

Visa Sponsorship

Guardian is not currently or in the foreseeable future sponsoring employment visas. In order to be a successful applicant. you must be legally authorized to work in the United States, without the need for employer sponsorship.

Current Guardian Colleagues: Please apply through the internal Jobs Hub in Workday.