Job Responsibilities

·Provides professional medical, technical, consulting advice, and recommendations in support of claims 

evaluation, investigation, and assessment for various claims-related departments, while managing assigned 

caseload of complex cases applying specialized training and knowledge to the assessment of cases and acting 

as a resource on clinical and technical issues.

·Conducts complex research, review and analysis of medical records, treatment plans and claim information.

·Provides recommendations regarding claimants’ current potential functional abilities and develops

goal-focused return-to-work plans.

·Assess training needs and creates, authors, and presents medical training to claim and business partner

associates.

·Engages claimants, healthcare providers, employers, and customers to ensure strict adherence in determining 

functional abilities.

·Engages claimants, health care providers and employers in return to work potential and planning while 

coaching claim specialists on identifying and acting upon return-to-work potential.

·Creates effective requests for medical information which focus on clarifying medical restrictions and 

limitations and their impact on work functionality. Performs other related duties as assigned or required

Education, Technical Skills & Other Critical Requirement

Education

Bachelor’s degree (Medical) or diploma with a minimum of 15 years of education

Master’s degree in clinical psychology or social work.
If Registered Nurse will accept associate degree or higher with current RN state license

(Anyone from below)

·Nursing + MS (Master of Science) in Psychology

·Nursing + MS (Master of Science) in Psychiatry

·Nursing + BA (Bachelor of Arts) in Psychology

·MA (Master of Arts) in Psychology + PhD (Doctor of Philosophy) in Psychology

·MPhil in Clinical Psychology

·Licensed Clinical Psychologist-licensed in behavioral unit

·Options -Licensure, social work, professional counselling

·MS (Master of Science) in Psychology with 2 years of clinical experience

·MS (Master of Science) in Psychiatry with 2 years of clinical experience

·MA (Master of Arts) in Psychology with 2 years of clinical experience

·MPhil in Clinical Psychology with 2 years of clinical experience

·MBBS + Diploma/Degree in Psychiatry +2 years of Clinical experience

Experience 

(In Years)

Required

·Current RN licensure

·2 + years of experience as an RN with Clinical/Ops Experience (Specially in Physiatry/Psychology)

Preferred

·2+ years Disability claims and/or clinical experience

·Licensure in Clinical Psychology or Social Work & 2 years of experience in inpatient or intensive outpatient or outpatient therapy in a clinical setting 

·Value added- Nursing background with behavior health (including MHU +BHU)

·Disability claims experience

·Preferred designations CCM (certified case management) and/or CDMS (certified disability management specialist).

Technical Skills/other skills

·Computer navigation skills

·Excellent Keyboarding and data entry speed

·Knowledge about US Culture is preferred.

·Excellent verbal/written communication skills – should be able to read, interpret business documents.

·Excellent analytical and interpersonal skills 

·Data gathering ability/ Eye for detail. 

·Ability to comprehend and apply varied rules to multiple policies.

·Teamwork/ Managing Self / Adaptability 

·Ability to work successfully and perform detail-oriented work in production driven environment. 

·Excellent organizational skills

·Proven ability to meet quality and time standards.

·Ability to work on routine/standardized transactions.

·Possess strong knowledge of medical conditions, symptoms, and terminology.

Other Critical Requirements Like Voice/ Non-Voice for Insurance Ops

Blended

Complexity Scale: 9/T5C5