Insurance Services
Full Time
Day Shift
Mon-Fri 8am-5pm
Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked #2 in the state and #1 in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of the Best Places to Work in South Carolina.
The 607-bed teaching hospital anchors a health care network that includes five community medical centers and employs more than 8,000 health care professionals. The network includes a cardiovascular program recognized by the American College of Cardiology as South Carolina’s first HeartCARE CenterTM and an accredited Cancer Center of Excellence affiliated with MUSC Hollings Cancer Center for research and education. The network also features an occupational health center, the largest skilled nursing facility in the Carolinas, an Alzheimer’s care center and nearly 80 physician practices. Its postgraduate medical education programs include family medicine and transitional year.
Job Summary
The Insurance and Claims Nurse Analyst will be responsible for all clinical analysis and evaluation of claims and related insurance matters. This role will be an integral part of the Insurance Services Department with the goal of reducing risk exposures and effectively managing liability. A core function is the clinical evaluation of events and assisting in determining efficient claim resolution.
Minimum Qualifications
Minimum Education: Bachelor of Science in Nursing
Minimum Years of Experience: 5 Years of experience as a registered nurse, including at least 1 year in nursing administration (e.g. nurse management, risk management, quality assurance, or case management experience)
Substitutable Education & Experience: None.
Required Certifications/Licensure: Currently licensed as Registered Nurse by the State Board of Nursing for South Carolina.
Required Training: Computer skills are essential as much of the role will require Microsoft Office and other software.
Essential Functions
- Knowledge of general nursing practices and medical care standards.
- Serve as a resource for Insurance Services and other staff by explaining medical terminology, medical documentation, and expected standards of care.
- General knowledge of insurance claims management, including, but not limited to, claim evaluation and investigation.
- Request, review, and analyze medical documentation as related to the provision of care delivered by healthcare providers in all healthcare settings.
- Review and conduct analysis of medical records and documentation associated with professional liability, general liability, and other related claims.
- Collaborate with staff to provide clinical expertise in the investigation, evaluation, and resolution of claims.
- Apply clinical knowledge and experience in analyzing and interpreting complex medical documentation and provide recommendations for further claims handling.
- Review and evaluate allegations of medical malpractice and negligence and the circumstances surrounding the events to determine if further investigation is warranted.
- Provide guidance regarding pre-existing conditions, past injuries, medications, treatment gaps, and noncompliance and their impact on claims and litigation.
- Prepare detailed medical chronology reports and summaries of medical records.
- Assist Insurance Services and legal counsel as clinical resource in case preparation and discovery as needed.
Duties & Responsibilities
- Communicate with legal counsel and other parties in regards to actual and/or potential claims facing the organization.
- Consult and communicate with professionals and experts (i.e. Physicians, engineers, and outside legal counsel).
- Conduct assessments and evaluations to determine risk management issues to decrease liability issues and exposure.
- Meticulously maintain and update documentation and databases, including electronic claim management system.
- Assist in controlling the cost of processing claims.
- Provide data analysis and prepare and process detailed reports.
- Conduct medical and nursing research, including, but not limited to, research on current market/organizational risk initiatives.
- May provide training and education to other staff as needed and at the direction of Department leaders in Insurance Services.
- Maintain high level of clinical expertise on injury-related topics.
- Attend trainings to stay up-to-date with trends and information regarding nursing and medical care.
- Other duties as assigned at the direction of Department leaders in Insurance Services.
We are committed to offering quality, cost-effective benefits choices for our employees and their families:
- Day ONE medical, dental and life insurance benefits
- Health care and dependent care flexible spending accounts (FSAs)
- Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%.
- Employer paid life insurance – equal to 1x salary
- Employee may elect supplemental life insurance with low cost premiums up to 3x salary
- Adoption assistance
- LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
- Tuition reimbursement
- Student loan forgiveness
Equal Opportunity Employer
It is the policy of LMC to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. LMC strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. LMC endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.
