Clinical Care Advocate II

Provides a detailed comprehensive review of injury event, to provide recommendations to 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. Actively engaged with Claims Adjusters and Case Managers for movement of file, to identify issues, obstacles and implement strategies for resolution. Can encompass working as a return-to-work coordinator within client specific guidelines; coordinates and maintains outcomes of claim file reviews; coordinates and maintains outcomes of complex claim reviews; reviews and provides outcomes of reviews of take-over claims; works with analytics on various projects to enhance outcomes and client experience.

• Addition to the skill set in Clinical Care Advocate I, the Clinical Care Advocate II position expands the scope of the nursing practice to include:
• Assessment
  
  
  
  • Initially reviews injury event, clinical documentation, treatment plan notated in the claim notes, identifying all issues and obstacles.
  • Review new takeover claims identified for clients, maintains excel spreadsheets for Account Executive and Client with recommendations to claims adjusters and case managers.
  
  
• Initial Plan Development
  
  
  
  • Clinical Care Advocate develops medical management plan utilizing evidence-based medicine and communicates the plan to appropriate stakeholders and schedules follow-up review.
  
  
• Follow-up with stakeholders
  
  
  
  • Clinical Care Advocate schedules and participates in follow up discussions as needed with all stakeholders to formulate plans to address obstacles.
  
  
• Claim progress towards resolution
  
  
  
  • Continuously analyzes effectiveness of treatment in comparison to treatment plan, in terms of the injury, cost effectiveness, suitability of services for prognosis of condition, injured worker's willingness to adhere to treatment plan until a return to full duty or maximum medical improvement.
  • Actively participates or coordinates in monthly/quarterly claim file reviews, depending on client Clinical Care Advocate may be required to host claim files reviews, present claims and document identified strategies to implement.
  • In states where where the CCA is appropriately credentialled, they may contact the employer, provider and/or injured worker to determine treatment status and coordinate RTW.
  • In states where the CCA is appropriately credentialed, they may participate in documentation of the medical status as well as the RTW Status on various computer platforms.
  
  
• Medical Management Resource
  
  
  
  • The Clinical Care Advocate functions as the medical management resource/expert, providing information to the claim reviewed.
  • When identified training to enhance knowledge of the Clinical Care Advocate role to claims, case managers, and clients as indicated.
  • Actively participates on claim file reviews, roundtable discussions, special projects and task forces.
  • Depending on client's expectations, Clinical Care Advocate responsibilities may include RTW coordination of claims with follow up with case managers and adjusters.
  • Actively work with the Analytic team to enhance data capture, usage, and dissemination of information.
  • Work with focus group to share information and system needs to enhance Clinical Care Advocate workflow to make more efficient.
  • Create excel spreadsheet to include client complex cases to discuss progress/obstacles at scheduled monthly meeting with client (sent out prior to meeting for client review).
  
  

• Individuals must hold a current, registered nurse professional license without restrictions to practice as a health professional in a state or territory of the United States.
• Associates degree in Nursing, Bachelor's degree in Nursing preferred.
• Individuals must hold a current, nationally recognized certification (CCM, CRRN, COHC, CRC) without restrictions to practice in the United States.
• Minimum of two years Case Management experience preferred
• Minimum eight years of clinical experience preferably in a varied clinical environment preferred
• Minimum two years as a CCAI or Sr Case Manager preferred
• 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.
• Individuals who conduct initial clinical review possess a current, professional license or certification:
  
  
  
  • To practice as a health professional in a state or territory of the U.S.; and
  • With a scope of practice that is relevant to the clinical area(s) addressed in the initial clinical review.
  
  
• Must be able to travel as required.

#LI-RG1

• Pay and incentive plans that recognize performance excellence
• Benefit programs that empower financial, physical, and mental wellness
• Training programs that promote continuous learning and career progression while enhancing job performance
• Sustainability programs that give back to the communities in which we live and work
• A culture of respect, collaboration, entrepreneurial spirit and inclusion