Clinical Nurse Specialist

Job Responsibilities and Requirements

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*

Required Knowledge, Skills, Abilities and/or Related 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.

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 why we offer a competitive pay package and a range of benefits to help team members thrive in their financial, physical, and mental wellbeing.  

Our Benefits:

• An annual performance bonus for all team members
• Generous 401(k) company match that is immediately vested
• A choice of three medical plans (that include prescription drug coverage) to suit your unique needs.  For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account
• Multiple options for dental and vision coverage
• Company provided Life & Disability Insurance to ensure financial protection when you need it most
• Family friendly benefits including Paid Parental Leave & Adoption Assistance 
• Hybrid work arrangements for eligible roles
• Tuition Reimbursement and Continuing Professional Education
• Paid Time Off – new hires start with at least 20 days of PTO per year in addition to nine company paid holidays.  As you grow with us, your PTO may increase based on your level within the company and years of service. 
• Volunteer days, community partnerships, and Employee Assistance Program
• Ability to connect with colleagues around the country through our Employee Resource Group program

Our Values:

• Integrity
• Empowerment
• Compassion
• Collaboration
• Fun

EEO Statement

Reliance Matrix is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability, or any other classification or characteristic protected by federal or state law or regulation. We assure you that your opportunity for employment depends solely on your qualifications.