Job Summary:
The Claims/Underwriting Assessment Clinical Auditor is responsible for the timely and accurate review of a Benefit Eligibility Assessment (BEA) conducted by a Field Nurse Assessor. The audit entails a thorough review of the BEA to ensure the field Nurse Assessor appropriately completed the entire assessment tool, correctly applied, and scored the cognitive test section, and accurately completed the functional assessment conducted for Long-Term Care Insurance policyholders. Interacting with the Field Nurse Assessors, the Clinical Nurse Reviewer may need to obtain clarifications to documentation submitted, provide training to Nurse Assessors who are new or need retraining on completing the BEA tools, and conduct virtual and telephonic assessments with other health care providers when an assessment/reassessment is needed for a claimant residing in a long-term care facility. The Clinical Nurse Reviewer responds to clinical questions from long term care insurers and provides input on the quality of the Field Nurse Assessors upon completing their review.
Essential Job Functions:
- Conduct thorough and accurate reviews of completed assessment documents.
- Successfully follow up with Field Nurse Assessors to clarify/correct responses written in the BEA tool, where needed.
- Deliver exceptional customer experience through service, responsiveness and respectful interaction.
- Ability to provide comprehensive education to Field Nurse Assessors on how to accurately complete a Benefit Eligibility Assessment (BEA), Plan of Care (POC), and Chronic Illness Certification (CIC), in an individual or group setting via the phone to ensure a quality assessment is performed.
- Complete virtual and telephonic assessments of claimants and caregivers, when necessary.
- Ability to maintain patient confidentiality and process information in a confidential manner
- Perform other related duties as assigned.
Performance Expectations:
- Complete a comprehensive review to ensure the quality of the completed assessment, in a timely and efficient manner.
- Ability to collaborate, communicate and demonstrate professionalism with internal and external individuals
Required Skills/Abilities:
- Previous experience in a clinical setting, preferrable in geriatric care.
- Ability to work independently.
- Ability to multitask, prioritize, and manage time efficiently, while maintaining high quality review.
- Must be highly process-oriented, demonstrating strong judgment and attention to detail.
- Effective problem solving and prioritization skills
- Commitment to follow-through, while maintaining adaptability in a dynamic and evolving work environment.
- Exhibit compassion and excellent customer service skills.
- Capacity to stay calm under pressure and handle stress effectively.
- Strong knowledge of Windows, Microsoft Suite
Required Education and Experience:
- Active Licensed Clinical Social Worker LCSW), Master’s of Social Work (MSA), or a Licensed Social Worker (LSW).
- One-year previous related experience in a healthcare environment.
- Active and unrestricted RN license in good standing
Physical Requirements:
- Ability to work and sit at a desk for prolonged periods of time working on a computer.