Role Value Proposition:
Global Technology & Operations (GTO) includes over 17,000 associates across 42 countries Service our customers in operations and global customer call centers where we deliver global support services, including global real estate, global corporate security, and global innovation. This role, for a Clinical Support Consultant – Appeal Nurse Consultant, will support the Appeal Department by providing clinical expertise, and timely analysis of the medical information for adverse claim decisions under appeal review.
- Responsible for proficiently assessing, correlating, and applying relevant clinical, functional capacity, and plan provision information, with then providing recommendations regarding the claimants' current or potential functional abilities and/or deficits, or provides resource referral recommendations
- Assesses medical records for all line of appeals, including but not limited to: STD/LTD/LTC/Premium Waiver claims, comparing duration control guidelines as applicable, and clarifying functional inconsistencies, in order to assist in determine residual abilities and/or deficits.
- Ability to work telephonically as may be indicated with: claimants, physicians, medical directors, employers/customers, appeal specialists, peers/colleagues, Appeal Unit Leaders, Appeal Clinical Unit Leader, legal department, or other resources or partners, in order to effectively assist in determining and clarifying functional abilities, while providing clear clinical direction both verbally and in writing, as well as providing clear and concise documentation.
- Works with management to identify and address continuing education needs, and provides education on medical, disability, and/or system and procedural issues, to Appeal Team Associates
- Engages and/or recommends appropriate and cost effective internal and or external resource use
- Actively participates in the appeal clinical team, in order to meet team productivity, quality, and timeliness standards and goals, with the focus of complying with Employee Retirement Income Security Act (ERISA); standards, processes and procedures.
- Completes special projects as assigned by the ACUL (Appeal Clinical Unit Leader).
- Serves as a visible leader in translating MetLife's vision and values into practical business strategies. Demonstrates knowledge of, and supports, MetLife Disability mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality standards, and the code of ethical behavior.
- Performs other duties as assigned or required.
Essential Business Experience and Technical Skills:
- Bachelors in Nursing
- 5+ years clinical experience.
- Current RN licensure.
- Must have a minimum of 5 years of experience in Disability, combination of STD and LTD
- Master’s Degree in Nursing
- 7+ years Disability claims and/or clinical experience
- Disability claimsexperience
- Preferred designations CCM (certified case management), Legal Nurse Consultant and/or CDMS (certified disability management specialist)
- Possess strong knowledge of medical conditions, symptoms and terminology.
Requisition #: 103108