PURPOSE OF JOB CLASS (NATURE OF WORK)
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; knowledge of relevant State and Federal laws, statutes and regulations; knowledge of principles and practices of nursing care administration for a variety of specialties with varied settings; knowledge of health insurance and managed care practices; knowledge of state insurance law; some knowledge of the impact of the federal Employee Retirement Income Security Act (ERISA) on state regulation of insurance; considerable interpersonal skills; oral and written communication skills; considerable ability to problem solve; ability to understand and communicate health programs and insurance plans; ability to understand external insurance appeal processes; ability to prepare cases for presentations to insurance providers; ability to 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
1. A Master's degree in nursing may be substituted for the General and Special Experience.
2. A Master's degree in health services administration or public health may be substituted for one (1) additional year of the General Experience.
3. A Bachelor's degree in nursing may be substituted for one (1) year of the General Experience.
1. Incumbents in this class must possess and maintain a current license as a registered professional nurse in Connecticut.
2. Incumbents in this class may be required to travel.
3. 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)
This replaces the existing specification for the class of Nurse Advocate in Salary Group HC 24 approved effective February 20, 2015. (Revised to change Pay Plan and modify Substitutions Allowed)