PLADS Clinician Reviewer Job in Farmington

PLADS Clinician Reviewer

Company:  Aflac Columbus

The Location:  Remote, US Farmington, CT, US, 06032

The Division:  PLADS

Experience: 3 + Years

Job Id:  3542

 

Job Description

PLADS Clinician Reviewer

 

The Clinician Reviewer performs claims reviews of both short- and long-term disability claims from a clinical perspective and serves as an integral partner with disability case managers in negotiating therapeutic transitional return to work plans with treating providers, employees and occasionally employers.

 

Principal Duties & Responsibilities

  • Serves as a clinical subject matter expert to disability case managers and provides well-reasoned and timely clinical analyses related to functional impairment and work capacity
  • Through a clinical advocacy approach the clinician partners with case managers on return-to-work plans via contacts with treating providers and employees as needed
  • Assists in investigating and resolving inconsistencies in the level of employee functionality related to treating provider opinions and projections of incapacity and impairment
  • Coordinates strategies to determine levels of employee functional capacity utilizing direct contact with treating providers and/or utilizing internal clinical resources (e.g. Medical guidelines, Independent Physician Advisor Reviews, internal impairment guides, round table reviews, etc.)
  • Acts as a clinical consultant and resource to the Appeals Unit and attends short-term to long-term disability transition meetings as needed
  • Provides continuing education for case management staff via mini-clinical lectures and assists in the development of clinical tools/guides/training under the direction of Medical Director
  • Additional Responsibilities:
  • May act as a clinical resource to Claim Operations staff when handling claimants noted to be threatening harm to themselves or others
  • Assists in the development of clinical tools, templates, processes, and protocols under the direction of the Medical Director
  • Facilitates referrals to ancillary internal and external services, e.g., EAP, disease management programs, Advocacy, care managers, etc. as applicable
  • Coordinates and monitors quality of external physician advisor reviews or IME’s as applicable
  • Identifies employee barriers in returning to work as well as identifying and prompting optimal health care to facilitate an appropriate and timely return-to-work plan and strategy
  • Strategizes with claimants, treating providers, and employers on possible accommodations or restriction to facilitate transitional return-to-work plans
  • Performs other related duties as required

 

Education & Experience Required

 

  • Bachelor’s Degree in Nursing or advanced degree in medicine, e.g., NP, PA, MD or DO 1 year of related work experience
  • 3 years of experience in the field of health care working directly with patients
  • Current medical license in the state of residence
Education & Experience Preferred
  • 2 or more years of experience in the disability management industry managing STD or LTD claims
  • CDMS or CCM certifications
  • Utilization Review Experience and/or experience using specific behavioral health criteria or protocols

Or an equivalent combination of education and experience

 

Job Knowledge & Skills

 

  • Extensive clinical experience/knowledge
  • Knowledge of medical diagnoses and ICD-10 codes
  • Strong investigative and analytical skills
  • Strong customer service and advocacy skills
  • Strong written and oral communication skills
  • Strong organizational and time management skills
  • Ability to analyze health care records in the context of functional capacity related to work demands
  • Strong desire and ability to work in a team environment
  • Flexibility and coachability in the context of organizational growth and process change and development
  • Demonstrated ability to prioritize workload in a fast-paced environment, with proven organization and time management skills.

 

Competencies

 

  • Acting with Integrity
  • Communicating Effectively
  • Pursuing Self-Development
  • Serving Customers
  • Supporting Change
  • Supporting Organizational Goals
  • Working with Diverse Populations

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