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

Family Medical Care Plan (FMCP) jobs

Nurse - Participant Advocacy Specialist - Utilization Review