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Clinical Nurse Mgr in Kennesaw, GA at Tokio Marine HCC

Date Posted: 5/30/2018

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    Kennesaw, GA
  • Job Type:
    Insurance
  • Experience:
    Not Specified
  • Date Posted:
    5/30/2018

Job Description



Position Summary: 



Manages the Specialty Claims and Logix Departments for the purpose of clinical and claims review and management for the purpose cost savings outcomes.



Key Responsibilities:

Relying on broad knowledge and strong leadership skills, the Clinical Nurse Manager is accountable for the following responsibilities and has substantial latitude for actions or decisions made with minimal review.

 

  • Determine the process and manage Logix staff handling the review of clinical and claim data for course of treatment and cost projection for referral to Specialty Claims and Preliminary Claims Units in order to coordinate claims with respective vendors.

  • Determine the process and manage Specialty Claims Unit staff handling Transplant, Neonate and other cases, including appropriate vendor referral, internal case management, and cost savings.

  • Reserve review and oversight for Logix, Specialty Claims Unit, and Medical Underwriting staff.

  • Oversee the processing of claims related to Transplant, Neonate, or other cases including documentation, investigation, evaluation, negotiation, reserving and handling of funds, and equitable settlement.

  • Maintain claim files, both physical and electronic. Update files as needed.

  • Establish and maintain relationships, fees, and contracts with Vendors.

  • Negotiate claim settlement for Specialty Claims Unit cases but must seek approval for claims outside defined limit.

  • Provide supervision and guidance to less experienced Claims personnel including the review of settlement payments and denials for Specialty Claims Unit cases.

  • Communicate directly with payer/broker to obtain all necessary clinical information regarding claim. 

  • Provide timely and accurate reporting to management and other internal clients including summaries of open/closed claims, cost savings, or other related bordereaux.

  • Acts as a resource to other claims departments regarding prognosis of specific cases, review of questionable treatment, and similar issues.

  • Medical Underwriting Nurse resource and liaison to claims.

     

Job Requirements

Position Knowledge, Skills, and Requirements:

 

Education

  • Nursing Degree and Current Nursing License, ADN or BSN

     

Experience

  • Experience in Claims

  • Leadership experience