Insurance & Claims Analyst- RN (Onsite position, NOT remote)

Job Summary

The Insurance and Claims Nurse Analyst will be responsible for all clinical analysis and evaluation of claims and related insurance matters. This role will be an integral part of the Insurance Services Department with the goal of reducing risk exposures and effectively managing liability. A core function is the clinical evaluation of events and assisting in determining efficient claim resolution. 
 

Minimum Qualifications

Minimum Education:  Bachelor of Science in Nursing
Minimum Years of Experience: 5 Years of experience as a registered nurse, including at least 1 year in nursing administration (e.g. nurse management, risk management, quality assurance, or case management experience) 
Substitutable Education & Experience: None. 
Required Certifications/Licensure: Currently licensed as Registered Nurse by the State Board of Nursing for South Carolina.
Required Training:  Computer skills are essential as much of the role will require Microsoft Office and other software.

Essential Functions

• Knowledge of general nursing practices and medical care standards.
• Serve as a resource for Insurance Services and other staff by explaining medical terminology, medical documentation, and expected standards of care. 
• General knowledge of insurance claims management, including, but not limited to, claim evaluation and investigation. 
• Request, review, and analyze medical documentation as related to the provision of care delivered by healthcare providers in all healthcare settings. 
• Review and conduct analysis of medical records and documentation associated with professional liability, general liability, and other related claims.
• Collaborate with staff to provide clinical expertise in the investigation, evaluation, and resolution of claims.
• Apply clinical knowledge and experience in analyzing and interpreting complex medical documentation and provide recommendations for further claims handling.    
• Review and evaluate allegations of medical malpractice and negligence and the circumstances surrounding the events to determine if further investigation is warranted.
• Provide guidance regarding pre-existing conditions, past injuries, medications, treatment gaps, and noncompliance and their impact on claims and litigation.  
• Prepare detailed medical chronology reports and summaries of medical records. 
• Assist Insurance Services and legal counsel as clinical resource in case preparation and discovery as needed.

Duties & Responsibilities

• Communicate with legal counsel and other parties in regards to actual and/or potential claims facing the organization. 
• Consult and communicate with professionals and experts (i.e. Physicians, engineers, and outside legal counsel). 
• Conduct assessments and evaluations to determine risk management issues to decrease liability issues and exposure.
• Meticulously maintain and update documentation and databases, including electronic claim management system.
• Assist in controlling the cost of processing claims.
• Provide data analysis and prepare and process detailed reports.
• Conduct medical and nursing research, including, but not limited to, research on current market/organizational risk initiatives. 
• May provide training and education to other staff as needed and at the direction of Department leaders in Insurance Services. 
• Maintain high level of clinical expertise on injury-related topics.
• Attend trainings to stay up-to-date with trends and information regarding nursing and medical care.
• Other duties as assigned at the direction of Department leaders in Insurance Services.