Job Summary

The Clinician Reviewer performs claims reviews of both short- and long-term disability claims from a clinical perspective and serves as an integral partner with disability case managers in negotiating therapeutic transitional return to work plans with treating providers, employees and occasionally employers.

Principal Duties & Responsibilities

• Serves as a clinical subject matter expert to disability case managers and provides well-reasoned and timely clinical analyses related to functional impairment and work capacity

• Through a clinical advocacy approach the clinician partners with case managers on return-to-work plans via contacts with treating providers and employees as needed

• Assists in investigating and resolving inconsistencies in the level of employee functionality related to treating provider opinions and projections of incapacity and impairment

• Coordinates strategies to determine levels of employee functional capacity utilizing direct contact with treating providers and/or utilizing internal clinical resources (e.g. Medical guidelines, Independent Physician Advisor Reviews, internal impairment guides, round table reviews, etc.)

• Acts as a clinical consultant and resource to the Appeals Unit and attends short-term to long-term disability transition meetings as needed

• Provides continuing education for case management staff via mini-clinical lectures and assists in the development of clinical tools/guides/training under the direction of Medical Director

• Additional Responsibilities:

• May act as a clinical resource to Claim Operations staff when handling claimants noted to be threatening harm to themselves or others

• Assists in the development of clinical tools, templates, processes, and protocols under the direction of the Medical Director

• Facilitates referrals to ancillary internal and external services, e.g., EAP, disease management programs, Advocacy, care managers, etc. as applicable

• Coordinates and monitors quality of external physician advisor reviews or IME's as applicable

• Identifies employee barriers in returning to work as well as identifying and prompting optimal health care to facilitate an appropriate and timely return-to-work plan and strategy

• Strategizes with claimants, treating providers, and employers on possible accommodations or restriction to facilitate transitional return-to-work plans

• Performs other related duties as required

Education & Experience Required

• Bachelor's Degree in Nursing or advanced degree in medicine, e.g., NP, PA, MD or DO 1 year of related work experience
• 3 years of experience in the field of health care working directly with patients
• Current medical license in the state of residence

Education & Experience Preferred

• 2 or more years of experience in disability management industry managing STD or LTD claims
• CDMS or CCM certifications
• Utilization Review Experience and/or experience using specific behavioral health criteria or protocols

Or an equivalent combination of education and experience

Job Knowledge & Skills

• Extensive clinical experience/knowledge

• Knowledge of medical diagnoses and ICD-10 codes

• Strong investigative and analytical skills

• Strong customer service and advocacy skills

• Strong written and oral communication skills

• Strong organizational and time management skills

• Ability to analyze health care records in the context of functional capacity related to work demands

• Strong desire and ability to work in a team environment

• Flexibility and coachability in the context of organizational growth and process change and development

• Demonstrated ability to prioritize workload in a fast-paced environment, with proven organization and time management skills.

Competencies

• Acting with Integrity
• Communicating Effectively
• Pursuing Self-Development
• Serving Customers
• Supporting Change
• Supporting Organizational Goals
• Working with Diverse Populations