Specialist, Medical Claim Consulting

If you’re passionate about helping people protect what matters most to them, as well as innovating and simplifying processes and operations to provide the best customer value, then Nationwide’s Property and Casualty team could be the place for you! At Nationwide®, “on your side” goes beyond just words. Our customers are at the center of everything we do and we’re looking for associates who are passionate about delivering extraordinary care.

Ideal candidates will be located in central standard or eastern standard time zone.

Benefits Include: Medical, Dental, Vision, 401k with company match, Company-paid Pension plan, Paid time off, Holidays and more.

(Internal Use Only) Compensation Grade: F3

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Job Description Summary

Providing exceptional customer service and developing productive, trusting relationships with policyholders and claimants allow us to deliver on Nationwide’s promise. Complexity of coverage and the intricacies of medical claims offers variety of work and requires critical thinking and adaptability. If you can empathize, listen and protect confidential information and work collaboratively to resolve and pay claims, we want to hear from you!

As a Specialist, you'll provide medical consultation, support and claim file intervention for Claims partners, including guidance on issues related to life expectancy, reasonableness and appropriateness of treatment, medical or vocational cost projection and anticipated treatment needs over the life of the injured claimant. We'll count on you to create, coordinate, facilitate and/or implement medical training programs. In addition, you may coordinate or manage vendor programs and relationships, as well as cost containment, risk mitigation and regulatory compliance issues relative to medical claims.

Job Description

Key Responsibilities:

• Participates in and attends lawsuit file conferences, alternative dispute resolution sessions and medical depositions.

• Prepares claims staff and defense counsel for discovery processes, alternative dispute resolution and lawsuit file/trial strategy as related to case-specific medical issues.

• Presents medical training to Claims staff (including Claims Managers, Claims Representatives, Legal and Special Investigative Unit (SIU)) and defense counsel/trial division as directed and prepared by corporate medical management.

• Provides medical bill audit expertise and supports medical cost containment programs in accordance with corporate and state directives.

• Supports Claims Representatives in face-to-face meetings with claimants and/or attorneys to expedite negotiations and settlements.

• Participates in open and closed file reviews, to provide skill building opportunities for Claims professionals.

• Works with Claims and SIU to identify, investigate and prosecute medical fraud.

• Participates in roundtables and file conferences at the request of the Claims Manager.

• Supports the Claims Manager in the independent medical examination/peer review process and monitors quality of associated vendors.

• Completes complex injury file reviews at the direction of the Claims Manager.

• Supports corporate guidance and direction related to medical specialist standard methodologies.

May perform other responsibilities as assigned.

Reporting Relationship: Reports to Manager or Director.

Typical Skills and Experiences:

Education: College degree in nursing, business, insurance or other medical-related field preferred.

License/Certification/Designation: Registered Nurse or CCM preferred.

Experience: Minimum of five years in medical profession and/or claims experience preferred.

Knowledge, Abilities and Skills: Broad-based medical knowledge. Knowledge of medical and legal issues relating to property and casualty claims processes and practices, including common treatment protocols, medical billing practices, bill review, alternative dispute resolution and litigation processes. Ability to investigate and credibly contradict erroneous or exaggerated assertions regarding medical conditions and their relatedness. Ability to negotiate with