Disability Clinical Specialist

Disability Clinical Specialist

PRIMARY PURPOSE : Performs standard clinical evaluations on claims that require additional review based on medical condition, client requirement, and/or complexity. Consults with providers and employees by providing case direction and ensures medical information substantiates the need for employee absence from work.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Performs standard clinical reviews of referred medical claims based on client requirements to ensure accurate and sufficient information is received by employees and providers to support the claim request and documents decision rationale.

• Completes medical review of all claims by reviewing medical documentation received and applying practical clinical knowledge to ensure information substantiates disability and to interpret the impact the condition has on the ability to perform job functions.

• Communicates clearly and professionally, on the phone and/or in writing with employee and/or providers to discuss employee’s clinical status, progress, and work status.

• Provides clear and appropriate follow-up recommendations for ongoing medical management of claims; ensures appropriate recommendations are made on claims.

• Consistently achieves appropriate quality audit scores.

• Acts as clinical resource to claims examiners to provide guidance on the medical management of claims including comprehension of medical terminology and substantiating claim decisions.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Acts as a backup for key disability claims on an ad hoc basis.

• Performs other duties as assigned.

• Travels as required.

Qualifications

Education & Licensing

Bachelor's degree or equivalent preferred. Current RN, LVN, LPN, CRC, COHN CVE, LPC and/or LCSW Licenses required. Current license, registration and/or professional designations as required within the jurisdiction. Clinical expertise must be kept current by acquisition of the necessary CEUs to maintain licenses and designations.

Experience

Four (4) years of related experience or equivalent combination of experience and education required to include experience in a direct medical/psychological setting or physical industrial medicine and previous insurance or related experience.

Skills & Knowledge

• Knowledge of current medical practices in health care management in a variety of areas (including, but not limited to, orthopedics, general medicine for acute and chronic conditions, general surgery, mental health, obstetrics, oncology, and physical and occupational rehabilitation)

• Excellent oral and written communication, including presentation skills

• Proficient computer skills including working knowledge of Microsoft Office

• Analytical and interpretive skills

• Strong organizational and multitasking skills

• Excellent interpersonal skills

• Ability to exercise judgement and critical thinking skills

• Ability to work in a team environment

• Ability to meet or exceed Performance Competencies