MEMIC is seeking a Registered Nurse to join the team as a Workers' Compensation Nurse Specialist who is responsible for managing the day-to-day Managed Care Services (MCS) vendor partner performance per service level agreements and ensuring vendor conformity to department standards, operational processes and management guidelines to ensure business goals are achieved.
Reviews requests for referrals and determines which assignments remain in-house or are referred to managed care service vendor partners supporting the department’s strategic goals and budget.
Liaison for all claims outsourced to managed care service vendors. Evaluates assigned cases in collaboration with claim handler and vendor partner representative or Nurse Case Manager to make appropriate recommendations.
Oversees the day-to-day execution of managed care service vendor partner agreements to ensure compliance, quality, and when necessary, works with vendor to develop corrective action plans. Evaluates and reconciles invoices as needed.
Oversees external nurse case management caseload and vendor partner performance to ensure compliance with service level agreements. In collaboration with Director, Managed Care Services, implements corrective action when goals, metrics and objectives are not met regarding production, quality, and performance issues.
Produces operational reports to verify service level agreements are being met as well as calculates return on investment.
Participates in round-table and claim review discussions as needed.
In conjunction with Director, Managed Care Services, participates in the fact-based selection, implementation and termination of managed care services vendors by analyzing and verifying if service level agreements, statements of work and procedures meet the goals and objectives of the department.
Utilizes clinical and nursing knowledge to provide medical treatment recommendations and utilization review recommendations for both internal and external claims, as needed.
Current and active RN License required; multi-state licensure preferred.
Graduate of approved accredited nursing program required; BSN preferred.
Certified Case Manager (CCM) or Certified Disability Management Specialists (CDMS) professional designation required.
A minimum of two years two years of professional vendor management experience preferred.
Experience in workers’ compensation strongly preferred.
Strong business acumen is essential.
Excellent written and verbal communication skills as well as presentation skills are essential.
Proficient in Microsoft Office (Excel, Word, PowerPoint).
Project management experience is a plus.
Ability to analyze and find creative ways to solve problems a must.
Strong judgment, decision-making skills and negotiation skills are a must.
Accuracy and attention to detail are a must.
Establishes and maintains effective relationships with customers and gains trust and respect.
Values and delivers high quality, professional, responsive and innovative service.
About Maine Employers Mutual Insurance Company
The MEMIC Group includes MEMIC Indemnity Company, MEMIC Casualty Company, and parent company Maine Employers’ Mutual Insurance Company; all rated “A” (Excellent) by A.M. Best. As a super-regional workers’ compensation specialty insurer, The MEMIC Group holds licenses to write workers’ compensation across the country. The group insures more than 20,000 employers and their estimated 300,000 employees, and holds more than $1.3 billion in assets. The group maintains offices in Manchester, NH; Glastonbury, CT; Albany, NY; Weehawken, NJ; West Conshohocken, PA; Tysons Corner, VA; and Tampa, FL; in addition to its headquarters in Portland, ME.