Senior Associate, Nurse Case Manager

Business Unit Overview

Group Benefit Solutions delivers comprehensive insurance and absence management solutions for mid-size and large companies. Our work fosters a healthier, happier and more secure workforce, contributing to New York Life’s legacy of being there when we’re needed most. Here, you’ll design, implement and support these solutions directly impacting customers’ lives. At our core, we provide financial security and peace of mind to people through our absence, accident, disability, voluntary benefits and life insurance solutions.

Role Overview

The Nurse Case Manager is a licensed Registered Nurse who serves as a clinical consultant, partnering with Claim Managers to provide specialized clinical expertise in the evaluation of Short-Term Disability (STD) and Long-Term Disability (LTD) claims. Leveraging expertise in medical and behavioral health conditions, the Nurse Case Manager conducts comprehensive reviews of clinical documentation, evaluates the severity and functional impact of reported conditions, and assesses whether the available medical evidence supports the identified functional restrictions or demonstrates functional impairment. The role collaborates with claims professionals, treating providers, internal physician consultants, and other clinical/vocational resources to support thorough, consistent, and timely claim evaluations while maintaining a holistic, function-focused approach.

What You’ll Do

• Conduct comprehensive clinical reviews of STD and LTD claims involving medical, surgical, behavioral health, and co-occurring conditions. Integrate information from treating providers, customers, questionnaires, and other relevant sources to assess condition severity, functional impact, treatment response, expected recovery, comorbidities, and whether the available evidence supports identified restrictions and limitations or demonstrates functional impairment.
• Identify inconsistencies, gaps in clinical information, and areas requiring further clarification; formulate focused clinical questions; and recommend appropriate next steps, including requests for additional clinical information or records, provider or customer outreach, and physician or specialty review when warranted.
• Provide clear, objective, and well-supported clinical recommendations that support claim evaluation, assessment of functional status, and return-to-work considerations.
• Serve as a clinical resource by educating and consulting with Claim Managers while fostering collaborative relationships with internal business partners, physician consultants, and external healthcare providers.
• Document clinical findings, recommendations, and rationale in accordance with departmental standards, applicable policies, and regulatory requirements.
• Participate in quality assurance initiatives, departmental projects, training, and continuous process improvement activities.

What You’ll Bring

Required

• Current, unrestricted Registered Nurse (RN) license in the state of residence and, where applicable, the state of employment.
• Three to five years of clinical nursing experience, including demonstrated experience in behavioral health.
• Demonstrated knowledge of medical and behavioral health diagnoses, treatment modalities, psychopharmacology, and recovery principles.
• Experience reviewing and analyzing medical records, behavioral health documentation, diagnostic findings, treatment plans, and other clinical information relevant to functional assessment.
• Proficiency with Microsoft Office applications, electronic documentation systems, and other technology platforms used to support clinical review and case management.

Preferred

• Bachelor of Science in Nursing (BSN).
• Experience in disability insurance, disability case management, utilization management, managed care, or workers' compensation.
• Experience supporting medical and behavioral health disability claims within Short-Term Disability (STD), Long-Term Disability (LTD), or both.
• Knowledge of evidence-based disability management and return-to-work principles.

Skills and Competencies

• Strong clinical judgment, critical thinking, and analytical skills, with the ability to synthesize complex clinical information and evaluate its impact on function.
• Strong written and verbal communication and consultation skills, with the ability to convey complex clinical information clearly to clinical and non-clinical audiences.
• Ability to work independently while collaborating effectively with Claim Managers, healthcare providers, and multidisciplinary partners.
• Strong organizational and time-management skills, with the ability to manage multiple priorities, communicate effectively during real-time interactions, document concurrently, and navigate multiple systems in a fast-paced environment.
• Continuous improvement mindset, with the ability to identify opportunities to enhance clinical review processes, quality, consistency, and efficiency.
• Digital fluency and adaptability, including the ability to effectively use and adopt emerging technologies and AI-enabled tools in accordance with organizational policies and standards.
• Commitment to continuous learning and professional development.