Claims Acumen (Advanced): Applies the knowledge of claims philosophy, contracts, and policies and procedures for filing claims, assessing claims for accuracy and completeness, verifying eligibility, and adjudicating claims based on established criteria to handle complex, contestable, sensitive, and large benefit amount claims. Decision Making (Expert): Makes timely, data-driven decisions by understanding the probability of success, identifying risks, gathering business requirements, and developing value statements.

Primary Duties and Responsibilities

• Provide technical medical expertise and support to the Benefit Claims analysts through thorough review of claims to include evaluation and analysis of provider medical records, test results and course of treatment. Provide timely consultations with the analysts and identify when additional medical information is needed.

• Clearly communicate the disability claim assessment, rationale and recommendation with medical directors, outside consulting physicians and analysts regarding insured’s medical condition, clinical medical findings, significance of and support for claimed limitations, appropriateness of treatment and alternatives, expected duration of claim, and potential for rehabilitation or return to work.

• Through triaging of disability claim referrals, identify the need for and coordinate the handling of claim referrals with medical directors and outside consulting physicians. Acts as a liaison for the division with all medical resources to ensure that medical reviews are thorough and complete and adhere to the claim philosophy of the Benefits Division.

• Effective medical education and training for new disability benefits analysts. Prepare periodic presentations to the division to help ensure efficiency and consistency in administering medical claim protocols and processes.

• Participate and at times lead inter and intra departmental projects and committees

• Train new DI Benefit Medical Consultants when required and participate in peer auditing

• Occasionally partner with law department to help resolve claim medical disputes via negotiation and/or participation in litigation.

Qualifications

• A minimum of 5-8 years of professional experience preferably in critical care nursing, medical-surgical nursing or orthopedic nursing with a bachelor’s degree in nursing

• A minimum of 5-8 years of professional experience as a physician’s assistant or nurse practitioner and associated bachelor/master’s degree

• Consistent critical decision-making skills and flexibility in all aspects of work

• 2-3 years of successful complex claims assessment, rationale and recommendations and communication with physicians, analysts, lead consultants and teaching at the medical consultant level

• Ability to consistently assess claims independently with consistent high quality audit results in all categories

• Strong interest in self-development with demonstrated leadership, engagement, and ability to work independently as well as with a team

• Excellent interpersonal skills and proven ability to work effectively with others at all experience levels

• Superior written and verbal communication skills.

• Flexibility and willingness to change as job duties change

• Knowledge of computer functions and experience in a “Windows” environment.

• Experience in orthopedic medicine or physical medicine and rehabilitation

• Knowledge of disability insurance or prior experience in insurance claim management.

• Demonstrated leadership ability.

Skills You Have

• Medical Acumen (Expert): Applies knowledge of medical terminology, anatomy, and medical conditions, as well as an understanding of medical treatment options and limitations, to review and analyze medical/claim records. Utilizes understanding of medical needs and disease progression and applies contract provisions to various situations.

• Medical Case Consultation (Expert): Applies medical knowledge and clinical experience to provide consultation about a patient's medical condition in relation to benefits and underwriting.

• Decision Making (Expert): Makes timely, data-driven decisions by understanding the probability of success, identifying risks, gathering business requirements, and developing value statements.

• Claims Acumen (Advanced): Applies the knowledge of claims philosophy, contracts, and policies and procedures for filing claims, assessing claims for accuracy and completeness, verifying eligibility, and adjudicating claims based on established criteria to handle complex, contestable, sensitive, and large benefit amount claims. Evaluates medical, financial, and occupational information and reviews to determine if insured meets contractual provisions while taking the state regulations or other relevant contractual information into consideration to make informed decisions. Analyzes insurance claims to determine the validity/risk of the claim, and the extent of coverage.

• Dispute Resolution (Advanced): Resolves conflicts or disagreements between parties. Identifies the issues at hand, understands the perspectives of all parties involved, and uses effective communication and negotiation skills to find a mutually acceptable solution.

• Coaching & Mentoring (Advanced): Develops others by providing actionable, constructive feedback through the lens of technical expertise and offers guidance to others on how to leverage, prioritize, and develop skills to achieve one's goals and objectives.

• Adaptive Communication (Advanced): Formulates strategies to be used to convey complex information about services, products, systems, or processes to targeted audiences; communicates and liaises between technical and non-technical audiences.

Compensation Range:

Pay Range - Start:

$89,360.00

Pay Range - End:

$134,040.00

Geographic Specific Pay Structure:

Structure 110:

$98,320.00 USD - $147,480.00 USD

Structure 115:

$102,800.00 USD - $154,200.00 USD

We believe in fairness and transparency. It’s why we share the salary range for most of our roles. However, final salaries are based on a number of factors, including the skills and experience of the candidate; the current market; location of the candidate; and other factors uncovered in the hiring process. The standard pay structure is listed but if you’re living in California, New York City or other eligible location, geographic specific pay structures, compensation and benefits could be applicable, click here to learn more.

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Northwestern Mutual is an equal opportunity employer that welcomes talented individuals of all backgrounds. We are committed to creating and maintaining an environment in which each employee can contribute creative ideas, seek challenges, assume leadership and continue to focus on meeting and exceeding business and personal objectives.

Skills

Dispute Resolution (NM), Learning Agility & Critical Thinking (NM), Client Application Data Evaluation (NM), Medical Case Consultation (NM), Customer Centricity (NM), Insurance Acumen (NM), Specialized Training Delivery (NM), Coaching & Mentoring (NM), Medical Acumen (NM), Decision Making (NM), Claims Acumen (NM), Analytical Thinking (NM), Information Gathering, Claims Policies & Practices (NM), Attention to Detail (NM), Adaptive Communication (NM)

FIND YOUR FUTURE

We’re excited about the potential people bring to Northwestern Mutual. You can grow your career here while enjoying first-class perks, benefits, and our commitment to a culture of belonging.

• Flexible work schedules
• Concierge service
• Comprehensive benefits
• Employee resource groups