POSITION DESCRIPTION
POSITION: Nurse - Participant Advocacy Specialist
JOB CLASSIFICATION: Exempt
REPORTS TO: Director of Clinical Excellence and Participant Advocacy
JOB SUMMARY – The Participant Advocacy Specialist is an experienced nurse with extensive clinical knowledge who is responsible for direct participant and medical provider outreach. This includes working collaboratively with medical carrier clinical and non-clinical staff, performing comprehensive analysis of all relevant clinical information related to and compared with medical carrier clinical policy guidelines to ensure the appropriateness of all decisions rendered. The Specialist ensures that pre- and post-service claims are processed accurately. The individual will be an active and engaged member of the FMCP Participant Advocacy Committee.
PRINCIPAL DUTIES AND RESPONSIBILITIES
- Provide clinical support and knowledge to FMCP executives, management, and staff
- Ability to accurately interpret FMCP Summary Plan Description benefits
- Coordinate with appropriate FMCP staff to ensure a premier participant experience
- Demonstrate general knowledge of policies relevant to facility, state, and federal standards
- Work with key vendor contacts to maintain positive and productive collaboration
- Actively engage with participants, medical providers, and vendors to resolve pre-service authorization denials and post-service claims payment concerns
- Coordinate internal and external resources to meet identified needs
- Respond in a timely manner to operations leaders and stakeholders to facilitate informed decision-making
- Troubleshoot assigned issues, gather evidence, and investigate all relevant information with participants, vendors, and internal departments to resolve the problem in a cooperative and collaborative manner
- Other duties and projects as assigned
REQUIRED AND PREFERRED KNOWLEDGE, SKILLS, AND ABILITIES
- BSN or higher required
- 5+ years of acute care clinical nursing experience with an additional 5 years in a utilization or case management position; or any combination of education and experience which would provide an equivalent background
- Must have held clinical license in good standing; active license required
- Experience with care typically delivered in the outpatient and home health settings
- Experience navigating and successfully resolving prior authorization denials
- Prefer familiarity and experience working with Taft-Hartley Multi-Employer benefit plans
- Health Care and Quality Management (HCQM) or Case Manager certification
- A highly perceptive nurse able to solve moderately complex to complex clinical issues accurately, timely, and completely
- Maintains a flexible, positive, professional and cooperative demeanor
- Provides a high level of service and satisfaction to internal and external customers
- Willingness to work both independently and in collaboration with various clinical and non-clinical FMCP staff members
- Thorough knowledge of clinical standards
- A critical thinker with excellent verbal and written communication skills
- Proficiency with computer skills including but not limited to Outlook, Word, and Excel
- Excellent attention to detail and time management skills with a proven ability to meet deadlines
- Demonstrate honesty, integrity, compassion, and empathy in all interactions
- Willing and able to navigate difficult situations related to clinical and behavioral issues
- Demonstrate flexibility to successfully adapt to periodic changes in organizational needs
- Promotes direct, honest, open, and timely communication
- Previous claims administration knowledge
Job Type: Full-time
Benefits:
- 401(k)
- Dental insurance
- Flexible schedule
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
Application Question(s):
- Have you been employed by any medical carriers such as Anthem BCBS or Cigna?
- Do you have Utilization Review or Utilization Management Experience? If so how many Years?
- Do you have a BSN?
Experience:
- Acute Care Clinical Nursing: 3 years (Required)
Work Location: Remote
