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Medicare Set Aside Allocator: Sr Medicare Compliance Nurse RN
Sr Medicare Compliance Nurse
IF YOU CARE, THERE'S A PLACE FOR YOU HERE
For a career path that is both challenging and rewarding, join Sedgwick's talented team of 21,000 colleagues around the globe. Sedgwick is a leading provider of technology-enabled risk, benefits and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. Whether they have a workplace injury, suffer property or financial loss or damage from a natural or manmade disaster, are involved in an auto or other type of accident, or need time away from work for the birth of a child or another medical situation, we are here to provide compassionate care and expert guidance. Our clients depend on our talented colleagues to take care of their most valuable assets -- their employees, their customers and their property. At Sedgwick, caring counts®. Join our team of creative and caring people of all backgrounds, and help us make a difference in the lives of others.
Sedgwick's Medicare compliance team assists clients with Medicare Set-Asides (MSAs) and Medicare liens, which can impact workers' compensation and general, professional and auto liability claims. MSAs are reports created with the purpose of protecting Medicare's future interest in the event of a settlement. Our examiners use MSAs to negotiate settlements and the amount should provide funds for the claimant to treat their injury post settlement. We also assist with Medicare liens, which include any payments made by Medicare for the benefit of a claimant/plaintiff between the injury date and the settlement date. Our team reviews the liens for accuracy and handles any necessary negotiations to reduce them prior to settlement.
PRIMARY PURPOSE: To provide professional assessment, planning, coordination, implementation and reporting of complex clinical data; to complete complex Submissions revisions/updates in preparation for Medicare review and act as an internal resource regarding Centers for Medicare & Medicaid Services (CMS) guidelines.
ESSENTIAL FUNCTIONS and RESPONSIBILITIES
- Prepares and drafts complex Medicare Set-Asides (MSAs), Medical Cost Projects (MCPs), Submission cases, and related products; completes MCPs in preparation for reserve setting or settlement.
- Performs comprehensive medical record reviews and evaluates Workers' Compensation Medicare Set-Aside proposals to make recommendation to Centers for Medicare & Medicaid Services (CMS) for final determination based on applicable coverage policies, coding guide lines and utilization and practice guidelines.
- Reviews medical claims and completes complex file review for Medicare Set- Asides (MSA) and future medical cost projections.
- Serves as a consultant to Medicare Compliance Nurses on claims.
- Applies clinical knowledge and expertise with established clinical guidelines and provide clients with accurate and timely reviews of clinical referrals and a comprehensive analysis of medical treatment.
- Assists with providing required training to examiners handling medical/Medicare issues related to general liability and workers' compensation and mentors less experienced colleagues.
- Executes clear, concise and thorough medical record summary narratives for the purpose of inclusion in a Medicare Set-Aside or Future Medical Cost Projection.
- Assess, identify and document critical elements potentially impacting MSA cost projections for possible reduction and impact of any treatment guidelines and offers input to resolve issues.
- Records and completes documentation of the findings and analysis of medical records.
- Utilizes claims, legal, and/or nursing knowledge to analyze medical records and identify future medical treatment as documented in the medical records.
- Utilizes resource data bases for diagnoses, treatment guidelines, and prescription medication pricing, documenting the MSA allocation when applicable and finalizes the MSA allocation including cost projections.
ADDITIONAL FUNCTIONS and RESPONSIBILITIES
- Performs other duties as assigned.
- Supports the organization's quality program(s).
- Travels as required.
Education & Licensing
RN licensure required. Medicare Set-Aside Consultant Certified (MSCC) certification required. Bachelor's degree or equivalent from an accredited college or university preferred.
Six (6) years of related experience or equivalent combination of education and experience required to include five (5) years of MSA writing experience.
Skills & Knowledge
- Working knowledge of leave of absence, workers compensation and disability leave regulations
- Oral and written communication, including presentation skills
- PC literate, including Microsoft Office products
- Analytical and interpretive skills
- Strong organizational skills
- Good interpersonal skills
- Ability to work in a team environment
- Ability to meet or exceed Performance Competencies
When applicable and appropriate, consideration will be given to reasonable accommodations.
Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Physical: Computer keyboarding, travel as required
Auditory/Visual: Hearing, vision and talking
NOTE: Credit security clearance, confirmed via a background credit check, is required for this position.
The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.
Sedgwick is an Equal Opportunity Employer
Sedgwick Claims Management Services, Inc.is the leader in innovative claims and productivity management solutions to major employers. We provide cost-effective claims administration, managed care, program management and related services through the expertise of over 10,000 in 190+ offices and service locations. We are the largest, most innovative Third Party Administrator in the claims industry and the first and only TPA to receive recognition both as the “Best TPA in America” and “Employer of Choice.”
Sedgwick unique positioning allows you to “Claim Your Future.” We provide satisfying, challenging work along with a highly professional, friendly work atmosphere. We strive to make Sedgwick a place where great people can do great things for our clients. We express this commitment through our colleague development program, multi-dimensional learning resources, and commitment to work-life balance. Sedgwick offers exceptional benefits, including:
- Competitive compensation
- Comprehensive benefits (day one health benefits, STD, LTD, Life, 401(k) plus match, EAP, generous vacation and PTO)
- Flexible work schedules
If you desire a company where you can positively influence lives while maximizing your own career possibilities, Sedgwick is the place for you. Join our Talent Network to explore opportunities.
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