In the Office of the Healthcare Advocate, Consumer Affairs area this class is accountable for acting as a supervisor and responsible for independently performing a full range of duties related to health insurance consumer education, case management and advocacy and assessing compliance of health insurance companies with various state statutes, regulations and guidelines.
Works under the general supervision of a Supervising Nurse Consultant or other employee of higher grade.
May supervise/lead professional and clerical staff as assigned.
EXAMPLES OF DUTIES
Implements, coordinates, and evaluates activities of assigned programs or health care services;
Maintains active liaison with and serves as nursing consultant to other sections, divisions, health care providers and public;
Assesses safety and quality of client care provided;
Assesses compliance of health insurance companies with various state statutes, regulations and guidelines;
Within a unit, coordinates work flow and determines priorities to assure highest quality of consumer service;
Schedules, assigns, oversees and reviews work;
Establishes and maintains program protocols and procedures;
Provides staff training and assistance;
Conducts or assists in conducting performance evaluations;
Investigates consumer complaints against insurance companies;
Analyzes complaints for possible violation of state statutes, regulations and guidelines;
Leads internal case review;
Reviews medical records and consults with treating physician and other medical experts to build cases for "medical necessity" under Connecticut law;
Coordinates internal and external consumer appeals;
Liaison with health plan providers, consumers, families, government agencies;
Interviews consumers, families and providers to collect facts related to an appeal;
Drafts testimony for consumer and providers for appeal hearings;
Leads consumer presentation at appeal hearings;
Refers cases to other state agencies in consultation with Program Manager;
Assists in the design of and participates in agency quality improvement activities;
Develops and conducts outreach, presentations and front-line consumer education through the toll-free line or participates in health fairs;
May inspect and evaluate health care and psychiatric facilities for compliance with state and federal regulations including licensure and certification laws;
Performs related duties as required.
KNOWLEDGE, SKILL AND ABILITY
Considerable knowledge of
relevant state and federal laws, statutes and regulations;
principles and practices of nursing care administration and education for a variety of specialties with varied settings;
principles and practices pertinent to community processes;
health insurance and managed care;
internal and external insurance appeal processes;
state insurance law;
the impact of the federal Employee Retirement Income Security Act (ERISA) on state regulation of insurance;
medical procedures and billing codes;
state, federal and local health agencies and programs;
nursing education and skill in techniques of teaching;
oral and written communication skills;
plan, implement and evaluate programs;
collect and analyze data.
MINIMUM QUALIFICATIONS - GENERAL EXPERIENCE
Four (4) 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 a utilization review nurse or as a nurse working in the health insurance or healthcare industry on insurance coverage activities.
MINIMUM QUALIFICATIONS - SUBSTITUTIONS ALLOWED
A Bachelor's degree in nursing may be substituted for one (1) year of the General Experience.
A Master's degree in health services administration, nursing or public health may be substituted for one (1) additional 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 possess certification as an Insurance Rehabilitation Specialist or be eligible for certification as an Insurance Rehabilitation Specialist.
Incumbents in this class may be required to travel.
Incumbents in this class may be required to possess and retain 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 Consultant (Healthcare Advocate) (40 Hour) in Salary Group FP 28 approved effective October 17, 2022. (Revised to modernize format and add Acknowledgement section) Final No. 23-089