Clinical Care Advocate I (Finance)

Provides a detailed comprehensive review of injury event, to provide recommendations for direct medical management and coordination of services, utilizing evidence-based medicine, account criteria, state jurisdictional requirements ensuring the care they receive is the best from both a cost and medical outcome perspective. Acting as objective consultant, working closely with a multi-disciplinary team of medical professionals to provide proactive, clinically proven recommendations that help restore the lives of injured workers.

• Current RN home state licensure in good standing without restrictions with the State Board of Nursing.
• Associated degree in nursing or bachelor's degree preferred.
• Advanced nationally recognized certification such as CCM or CRRN.
• Minimum of 3 to 5 years of Case Management experience.
• Minimum 8 years of clinical expertise preferably in a varied clinical environment.
• Expertise in analytical problem solving, decision making with sound judgment, well organized with time management skills and excellent oral and written communication skills.
• Must possess a working knowledge of computers with the ability to use standard word processing, excel, and software applications.
• Effectively utilizes desktop tools to conform with State jurisdictional guidelines and account specific criteria.
• Exhibits a proven knowledge of multiple product lines and Services.
• Subject matter expert on Broadspire's medical management services.
• Demonstrates a proficiency in State Jurisdictional Guidelines and Account Specific criteria as applicable.
• Advanced certification in case management or other clinically relevant area (i.e. CCM, CRRN, ABQUAR, CPHQ, COHN, or QRP) is required.
• Maintain state licenses as requested.
• Must be able to travel as required.

• Review of claim event.
  • Initially reviews and gathers all information available in claims notes pertaining to the specific injury event.
• Strategize and implement plan.
  • After review of all information, develop and document a medical management plan utilizing available evidence-based medicine tools, communicate plan to appropriate claims adjusters/case managers, schedule follow-up reviews.
• Schedule follow up reviews.
  • Complete schedule reviews, participates in follow up collaboration as needed with claims adjusters/case managers to formulate updated plans to address identified obstacles or issues.
• Check for Progress updates.
  • Complete additional scheduled reviews, investigating for injury improvement, updated treatment plan to correlate. Recommend available Broadspire services to assist in resolution of identified issues/obstacles to claims adjuster/case manager. Schedule follow up review for confirmation of continued improvement.
• Review for Broadspire Services implemented correctly.
  • Review and confirm recommended/approved Broadspire services have been implemented with outcomes moving towards direction of resolution.
  • Reach out to other senior members on the Clinical Care Advocate team for additional guidance, direction of claim.