JOB SUMMARY:
The Clinical Nurse Advocate is responsible for collaborating with insurance companies, healthcare providers, and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues for enrolled membership.
ESSENTIAL FUNCTIONS:
- Review of a variety of health plan data and the ability to develop clinical findings.
- Use of clinical knowledge to work with health insurance carriers to ensure appropriate clinical care coordination.
- Work with employer to develop an appropriate a health risk management plan.
- Work closely with our Account Management Team to develop a cohesive plan to control costs within the health plan.
- Assist members in identifying participating providers that meet their needs and when appropriate, assist members in obtaining appointments with the provider.
- Assist members with access to medically necessary, quality healthcare in a cost effective setting
- Assist member in answering their complex medical questions.
- Assist members in locating available community resources.
- Development of a variety of health care education topics for represented membership.
- Assist members with appealing health carrier’s denial of medically appropriate care.
EXPECTATIONS/DESIRED SKILLS:
- Shows dedication to meeting the expectations and requirements of internal and external customers.
- Clearly understands importance of due dates, timelines, and expectations to the clients
- Relates well to diverse populations; builds appropriate rapport; listens; builds constructive and effective relationships; uses diplomacy and tact.
- Shows dependability for to successfully meeting goals; is a consistent, quality performer.
- Remains open and adaptable to change
- Applies effort and energy to lifelong learning and continual growth. Approaches job with an attitude of learning and curiosity.
- Maintains a positive work atmosphere by behaving and communicating in a manner so that relationships with clients, co-workers and supervisors are productive
- Provides regularity by attending work consistently and punctually
- Adapts to innovation within an ever-changing industry
QUALIFICATIONS:
Education & Experience
- Must be a Registered Nurse
- Certified Case Manager a plus
- At least 5 years of clinical experience preferably with an insurance company or Managed Care Company.
Qualifications and Essential Skills
- Demonstrated proficiency using Microsoft Office applications
- Dynamic personality with excellent presentation skills.
- Comfortable working with various data analytics platforms to identify gaps in care and mitigatable risk.
- Excellent written and verbal communication skills
- Excellent time management and project management skills
- Ability to articulate thoughts and speak clearly and professionally
Behavior Commitments
- Dedicated to meeting the expectations and requirements of internal and external customers
- Relates well to diverse populations; builds appropriate rapport; listens; builds constructive and effective relationships; uses diplomacy and tact
- Can be counted on to successfully meet goals; is a consistent, quality performer
- Applies effort and energy to lifelong learning and continual growth
- Approaches job with an attitude of learning and curiosity
- Maintains a positive work atmosphere by behaving and communicating in a manner so that relationships with clients, co-workers, and supervisors are productive
Additional Characteristics:
- Excellent organizational skills and attention to detail
- Proactive, dynamic personality, and highly motivated
- Ability to prioritize and manage multiple projects simultaneously
- Creative and results-driven
- Demonstrated ability to work independently with minimal supervision
- Able to work in a team-oriented, collaborative environment
PSA is an Equal Opportunity Employer.