Consultant, Claims Casualty
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AI Summary
Medical Cost Containment Consultant responsible for specialized workers’ compensation bill-review and medical cost-containment work.
The role requires medical judgment, coding and bill-review expertise, vendor and program knowledge, and close partnership with adjusters and managers. The responsibilities included prioritizing escalated bill reviews in the CEP-Medical queue, refining Capstone rules with the bill-review partner, scoping industry billing issues through the Enlyte portal, supporting adjusters with file reviews, roundtables, providing ODG guidance, helping develop training and provide consultative support for the broader team. The role provides both day-to-day operational support and strategic trend analysis aimed at improving billing accuracy, controlling medical inflation, and preserving claim quality and continuity. RN required with coding certificate required (If an internal applicant, coding certificate is preferred). If not currently a coder, certification would be expected within the first 6 months.
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Job Description Summary
Do you have a strong desire to resolve insurance claims by providing prompt, courteous and fair service to customers? Are you a skilled investigator, negotiator and communicator? If you thrive in an environment where you can problem-solve claims resolution, while following processes that provide fair resolution, customer satisfaction and cost management, then we want to hear from you!As a Consultant, you'll lead projects to achieve desired business objectives. This includes recommending, implementing and handling policies and procedures for existing and new business processes. We'll count on you to create and use tools and innovations that improve customer service, expense management and workflow.
Job Description
Key Responsibilities:
Coordinates and prioritizes all aspects of projects, including planning, communication, execution and completion.
Develops and controls timelines, including regularly re-assessing risks, throughout project life. Revises project plans on an ongoing basis to maintain alignment with other projects and the business strategy. Responsible for internal and external resource management, budgeting and cost containment.
Leads and implements business process mapping with respect to correcting data quality/integrity issues.
Recommends and implements innovations, tools, products policies and procedures that improve customer service, associate engagement, technical excellence, expense management and workflow and assists in managing these processes. Communicates changes to impacted business units. Provides training to associates and leaders on existing and new processes, products and tools.
Leads as point of contact for associates and leaders on specific products. Ensures products and tools are meeting associate and member needs.
Manages vendor relationships to ensure performance meets or exceeds expectations. Negotiates with large partners/accounts to improve services.
Serves as a subject matter authority for the leaders of other departments with issues and innovations. Acts as a liaison with associates to collect and provide feedback and serves as a technical resource.
Oversees design, development and execution of key tools, processes and initiatives and assists in designing training to improve performance and lower loss adjustment expense.
Responds to management and internal customers and state insurance departments, statistical bureaus or other regulatory agencies on compliance or data matters.
May perform other responsibilities as assigned.
Reporting Relationships: Reports to Director or Associate Vice President in the Casualty Technical Office; may lead a small team.
Typical Skills and Experiences:
Education: Undergraduate degree in a related field strongly preferred.
License/Certification/Designation: State licensing where required. Successful completion of required/applicable claims certification training/classes. CPCU, AIC or similar professional certifications preferred.
Experience: Seven to 10 years of work experience in claims, preferably in the casualty and litigation area. Management, facilitation, negotiation, delegation and mentoring experience. Business process mapping experience preferred.
Knowledge, Abilities and Skills: Knowledge of project management concepts and techniques. Understanding of business terminology, business systems and data processing policies, practices and procedures. Knowledge of business-related systems concepts and requirements. Excellent relationship-building skills. Exceptional project management skills such as organization and planning, interaction, leadership and motivational techniques. Strong negotiation skills and data quality/integrity problem solving skills. Administrative ability to plan, coordinate and assess the work of others, and strong personnel leadership skills in order to train, develop and empower staff. Decision making skills for problem identification and selection of alternatives. Strong verbal and written communication skills to interact with technical personnel and customers. Able to successfully influence and advise senior leaders. Technical report preparation and formal presentation skills. Able to operate effectively within required timelines and handle a significant workload.
Other criteria, including leadership skills, competencies and experiences may take precedence.
Staffing exceptions to the above must be approved by the hiring manager’s leader and Human Resource Business Partner.
Values: Regularly and consistently demonstrates Nationwide Values.
Job Conditions:
Overtime Eligibility: Exempt (Not eligible)
Working Conditions: Normal office environment. Occasional non-standard hours and travel. Must be willing to work extended hours and to travel with possible overnight requirements.
ADA: The above statements cover what are generally believed to be principal and essential functions of this job. Specific circumstances may allow or require some people assigned to the job to perform a somewhat different combination of duties.
Benefits
We have an array of benefits to fit your needs, including: medical/dental/vision, life insurance, short and long term disability coverage, paid time off with newly hired associates receiving a minimum of 18 days paid time off each full calendar year pro-rated quarterly based on hire date, nine paid holidays, 8 hours of Lifetime paid time off, 8 hours of Unity Day paid time off, 401(k) with company match, company-paid pension plan, business casual attire, and more. To learn more about the benefits we offer, click here.
Nationwide is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive culture where everyone feels challenged, appreciated, respected and engaged. Nationwide prohibits discrimination and harassment and affords equal employment opportunities to employees and applicants without regard to any characteristic (or classification) protected by applicable law.
This position could be filled within any of the lower 48 U.S. states.#claimsSmoke-Free Iowa Statement: Nationwide Mutual Insurance Company, its affiliates and subsidiaries comply with the Iowa Smokefree Air Act. Smoking is prohibited in all enclosed areas on or around company premises as well as company issued vehicles. The company offers designated smoking areas in which smoking is permitted at each individual location. The Act prohibits retaliation for reporting complaints or violations. For more information on the Iowa Smokefree Air Act, individuals may contact the Smokefree Air Act Helpline at 888-944-2247.For NY residents please review the following state law information: Notice of Employee Rights, Protections, and Obligations LS740 (ny.gov) https://dol.ny.gov/system/files/documents/2022/02/ls740_1.pdf
NOTE TO EMPLOYMENT AGENCIES:
We value the partnerships we have built with our preferred vendors. Nationwide does not accept unsolicited resumes from employment agencies. All resumes submitted by employment agencies directly to any Nationwide employee or hiring manager in any form without a signed Nationwide Client Services Agreement on file and search engagement for that position will be deemed unsolicited in nature. No fee will be paid in the event the candidate is subsequently hired as a result of the referral or through other means.
Nationwide pays on a geographic-specific salary structure and placement within the actual starting salary range for this position will be determined by a number of factors including the skills, education, training, credentials and experience of the candidate; the scope, complexity and location of the role as well as the cost of labor in the market; and other conditions of employment. If a Sales job, Sales Incentives, based on performance goals are possible in addition to this range. Note on Compensation for Part-Time Roles: Please be aware that the salary ranges listed below reflect full-time compensation. Actual compensation may be prorated based on the number of hours worked relative to a full-time schedule.The national salary range for Consultant, Claims Casualty : $97,000.00-$180,000.00The expected starting salary range for Consultant, Claims Casualty : $97,000.00 - $145,000.00Automatically Apply to the Best Remote Jobs
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