PURPOSE OF JOB CLASS (NATURE OF WORK)
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; may inspect and evaluate health care and psychiatric facilities for compliance with state and federal regulations including licensure and certification laws; assesses safety and quality of client care provided; assesses compliance of health insurance companies with various state statutes, regulations and guidelines; performs related duties as required.
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; performs related duties as required.
KNOWLEDGE, SKILL AND ABILITY
Considerable knowledge of health insurance and managed care; considerable internal and external insurance appeal processes; knowledge of state insurance law; knowledge of the impact of the federal Employee Retirement Income Security Act (ERISA) on state regulation of insurance; knowledge of medical terminology; knowledge of medical procedures and billing codes; considerable knowledge of relevant State and Federal laws, statutes and regulations; considerable knowledge of principles and practices of nursing care administration and education for a variety of specialties with varied settings; considerable knowledge of principles and practices pertinent to community processes; knowledge of State, Federal and local health agencies and programs; knowledge of nursing education and skill in techniques of teaching; considerable interpersonal skills; oral and written communication skills; ability to plan, implement and evaluate programs; ability to 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
1. A Bachelor's degree in nursing may be substituted for one (1) year of the General Experience.
2. A Master's degree in health services administration, nursing or public health may be substituted for one (1) additional year of the General Experience.
1. Incumbents in this class must possess and retain a current license as a registered professional nurse in Connecticut.
2. 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.
3. Incumbents in this class may be required to travel.
4. Incumbents in this class may be required to possess and retain a valid Motor Vehicle Operator’s license.
1. Administrative capacity shall be interpreted as having managerial responsibility in setting and implementing policies, carrying out program planning, and evaluating and coordinating special projects, etc. in the area specified in the appropriate parenthetical title.
2. Consultative capacity shall be interpreted as the providing of professional expert nursing advice to other than subordinate staff on major programmatic issues in the area specified in the appropriate parenthetical title.
3. Educational capacity shall be interpreted as experience in a full time professional educational position instructing professional nurses in a formalized program or teaching students in an undergraduate or graduate nursing program in the area specified in the appropriate parenthetical title.
4. Supervisory capacity shall be interpreted as the administrative supervision of registered nurses or other professional staff including accountability for hiring, firing, reviewing and evaluating employee performance in the area specified in the appropriate parenthetical title.
JOB CLASS DESIGNATION
(11)-HEALTH PROF (P-1)
This replaces the existing specification for the class of Nurse Consultant in Salary Group HC/FP 28 approved effective September 16, 2016. (Revised to establish a class code for the Department of Children and Families and modify content)