Job Summary:

The Nurse ConsultantManaged Care will serve as a liaison between the corporation in dealing with individual and institutional providers and with members to maximize quality of care and cost-effective utilization of services. At least half of the consultant's time will be spent in field work at provider facilities and member workplaces.

Supervisory Responsibilities:

• None.

Duties/Responsibilities:

• Informs providers about contract/benefit provisions together with correct use of CPT-4 and ICD-9 medical insurance coding to facilitate prompt processing of provider claims. Keeps providers aware of changes that will affect their procedures and billing practices.
• Answers questions from providers concerning clinical procedures and cost-effective practices to maximize quality of patient care.
• Addresses member groups to explain contract/benefit coverage and answer general questions about services available to members. Acts as a resource to sales staff.
• Participates in educational programs for members concerning preventive medicine maintenance practices such as proper nutrition, exercise, stress management, and smoking cessation programs.
• Offers members advice or assistance concerning unusual claims situations. Facilitates contacts in the organization to ensure proper review by specialized claims staff as warranted.

Required Skills/Abilities:

• Thorough knowledge of contract/benefit coverage, medical insurance coding (CPT-4 and ICD-9), claim review procedures, and payment practices.
• Excellent verbal and written communication skills combined with tact and good analytic judgment.

Education and Experience:

• Current RN license required with bachelor's degree preferred.
• Comprehensive knowledge of clinical procedures and practices based on a minimum of three years of current experience in an acute clinical setting.
• Valid driver's license to accomplish necessary travel.

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift up to 15 pounds at times.