Nurse Case Coordinator - Erie Insurance

Division or Field Office:

Claims Division
Department of Position: Corporate Claims Department
Work from:
Home in ERIE's Footprint Salary Range:
$76,115.00-$121,586.00*

salary range is for thislevel and may vary based on actual level of role hired for

*This range represents a national range and the actual salary will depend on several factors including the scope and complexity of the role and the skills, education, training, credentials, location, and experience of an applicant, as well as level of role for which the successful candidate is hired.Position may be eligible for an annual bonus payment.

At Erie Insurance, you're not just part of a Fortune 500 company; you're also a valued member of a diverse and inclusive team that includes more than 6,000 employees and over 13,000 independent agencies. Our Employees work in the Home Office complex located in Erie, PA, and in our Field Offices that span 12 states and the District of Columbia.

Benefits That Go Beyond The Basics

We strive to be Above all in Service® to our customers-and to our employees. That's why Erie Insurance offers you an exceptional benefits package, including:

• Premier health, prescription, dental, and vision benefits for you and your dependents.Coverage begins your first day of work.
• Low contributions to medical and prescription premiums.We currently pay up to 97% of employees' monthly premium costs.
• Pension.We are one of only 13 Fortune 500 companies to offer a traditional pension plan. Full-time employees are vested after five years of service.
• 401(k) with up to 4% contribution match.The 401(k) is offered in addition to the pension.
• Paid time off.Paid vacation, personal days, sick days, bereavement days and parental leave.
• Career development.Including a tuition reimbursement program for higher education and industry designations.

Additional benefits that include company-paid basic life insurance; short-and long-term disability insurance; orthodontic coverage for children and adults; adoption assistance; fertility and infertility coverage; well-being programs; paid volunteer hours for service to your community; and dollar-for-dollar matching of your charitable gifts each year.

Position Summary

Ensures all aspects of an injured party's medical treatment are appropriate, cost effective, efficient and in accordance with applicable legal requirements. Provides medical consultation and education to claims personnel. Provides assistance to the Medical Consultant.

• Successful candidate will work from Home and must live in ERIE's Footprint.

Duties and Responsibilities

Identifies inappropriate, experimental, overutilization or costly medical treatment.

Reviews precertification requests for medical necessity, referring those that require additional expertise to the Medical Consultant.

Complies with individual state legislation when applicable, regarding length of treatment guidelines and appeals time frames. Assures the timely and accurate determination and notification of medical treatment authorization, modification, delay or denial.

Analyzes medical records for assigned claims to assess validity of continued medical treatment and care. Determines if recommendations for medical care compare with the appropriate best practice standards as well as utilization of nationally recognized clinical guidelines.

Contacts providers to clarify treatment requests, examination findings and obtaining additional medical information as needed. Works with medical providers and suggests cost effective treatment alternatives, when appropriate.

Alerts claim adjuster to cases that may benefit from nurse case management services, utilization review and/or an independent medical examination.

Reviews and coordinates complex or catastrophic medical claims files submitted to the medical consultant for review. Ensures files are complete and organized, and highlights pertinent medical information.

Directs and develops medical and cost control guidelines and performance improvement initiatives for field claims staff as required.

Provides medical education and guidance to claims staff as needed.

Coordinates cost containment initiatives with medical service providers. Assists in the ongoing improvement of the Managed Care Program.

Completes special projects as required.

Assists in the development and enhancement of the Managed Care Program, including various financial, utilization review and medical management strategies. Utilize financial reporting information system to analyze financial and operational performance of the Managed Care program. Communicates and consults with the Medical Director regarding medical care, policies and procedures.

Duties and Responsibilities (cont'd if applicable)

The first sixduties listed are the functions identified as essential to the job. Essential functions are those job duties that must be performed in order for the job to be accomplished.

This position description in no way states or implies that these are the only duties to be performed by the incumbent. Employees are required to follow any other job-related instruction and to perform any other duties as requested by their supervisor, or as become evident.

Competencies

Job-Specific Knowledge

Values Diversity

Nimble Learning

Self-Development

Collaborates

Customer Focus

Cultivates Innovation

Instills Trust

Optimizes Work Processes

Decision Quality

Ensures Accountability

Qualifications

• The minimum education and experience requirements are as follows: Bachelor's degree, preferably in Nursing with three years experience in evaluating patient needs and medical documentation, or equivalent, required; or
• Associate's degree preferably in Nursing with five years experience in evaluating patient needs and medical documentation, or equivalent, required.

Registered nurse (RN) designation and current licensure required. Three years of Workers' Compensation Utilization Review experience, preferred. Five years clinical nurse experience with a preference for previous Orthopedic, Emergency Room, or Critical Care experience preferred. Willingness to pursue and successfully earn the Six Sigma designation, required. Strong knowledge of medical billing and documentation required. Valid driver's license and good driving record required.

Physical Requirements

Lifting/Moving 0-20 lbs; Occasional (
Lifting/Moving 20-50 lbs; Occasional (
Ability to move over 50 lbs using lifting aide equipment; Occasional (
Driving; Occasional (
Pushing/Pulling/moving objects, equipment with wheels; Occasional (
Manual Keying/Data Entry/inputting information/computer use; Frequent (50-80%)

Climbing/accessing heights; Rarely

Nearest Major Market: Erie