In the Office of the Health Care Advocate this class is accountable for independently performing a full range of duties by providing consultation and advocacy to consumers regarding health plan coverage and/or health care services.
Works under the general supervision of a Nurse Consultant or an employee of a higher grade.
May lead lower level employees as assigned.
EXAMPLES OF DUTIES
Serves as a resource to consumers, family members, health care providers, attorneys, government agencies and other interested parties on health care plan coverage and services;
Interprets health care plan coverage and provides guidance on an individual’s right to services;
Analyzes complaints for possible violation of state statutes, regulations and guidelines;
Conducts interviews and researches and gathers data to support insurance coverage and payment;
Investigates consumer complaints against insurance companies;
Reviews medical records and consults with treating physician and other medical experts to build cases for "medical necessity" under Connecticut law;
Assists consumers with the filing of complaints and appeals;
Advises consumers and providers on testimony and attends appeal hearings;
Ensures that appeal is properly documented and witnesses are prepared for appeal hearings;
Refers cases to other state agencies in consultation with supervisor;
Participates in health fairs and other forums;
Participates in internal case review meetings;
May conduct outreach;
Performs related duties as required.
KNOWLEDGE, SKILL AND ABILITY
Considerable knowledge of medical terminology and procedures;
relevant state and federal laws, statutes and regulations;
principles and practices of nursing care administration for a variety of specialties with varied settings;
health insurance and managed care practices;
state insurance law;
the impact of the federal Employee Retirement Income Security Act (ERISA) on state regulation of insurance;
oral and written communication skills;
Considerable ability to problem solve;
understand and communicate health programs and insurance plans;
understand external insurance appeal processes;
prepare cases for presentations to insurance providers;
utilize computer software.
MINIMUM QUALIFICATIONS - GENERAL EXPERIENCE
Three (3) years of experience as a professional nurse in a position involving medical/surgical or mental health practices.
MINIMUM QUALIFICATIONS - SPECIAL EXPERIENCE
Two (2) years of the General Experience must have been as a utilization review nurse or as a nurse in the health insurance or healthcare industry on insurance coverage activities.
MINIMUM QUALIFICATIONS - SUBSTITUTIONS ALLOWED
A Master's degree in nursing may be substituted for the General and Special Experience.
A Master's degree in health services administration or public health may be substituted for one (1) additional year of the General Experience.
A Bachelor's degree in nursing may be substituted for one (1) year of the General Experience.
Incumbents in this class must possess and retain a current license as a Registered Professional Nurse in Connecticut.
Incumbents in this class may be required to travel.
Incumbents in this class may be required to possess and maintain a valid motor vehicle Operator's license.
JOB CLASS DESIGNATION
(11)-HEALTH PROF (P-1)
As defined by Sec. 5-196 of the Connecticut General Statutes, a job class is a position or group of positions that share general characteristics and are categorized under a single title for administrative purposes. As such, a job class is not meant to be all-inclusive of every task and/or responsibility.
This replaces the existing specification for the class of Nurse Advocate (35 Hour) in Salary Group HC 24 approved effective March 17, 2017. (Revised to modernize format and add Acknowledgement section) Final No. 23-244