SUMMARY
The purpose of this position is to conduct an in-depth clinical analysis of disability pension case files to determine whether a causal relationship exists between the applicant's total disability, as defined by Social Security Administration, and the mine accident(s). Renders a professional opinion in narrative writing style. Reviews appeals and reconsideration claims.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:
Evaluates and analyzes medical, psychological, psychiatric, social, educational, vocational, and functional evidence in terms of relevance, consistency, reliability, and objectivity to determine if a causal relationship exists between the mine accident and the applicant’s Social Security disability.
Verifies and validates the applicant’s claimed mine accidents by applying the Plan’s eligibility requirements. Reviews medical records to identify additional mine accidents that may support the applicant’s claim for disability pension benefits.
Reviews, evaluates, and correlates the evidence of record obtained to establish whether the severity, duration, prognosis, and/or impact of impairment are sufficient to approve a Funds’ disability pension. Interprets an extensive variety of clinical data, extrapolates relevant facts from detailed records, which may include pre-existing conditions, psychiatric impairments, and later injuries that may aggravate the claimed mine accident injuries.
Contacts the Social Security Administration, coal companies, health care providers, insurance carriers, attorneys, and Workers’ Compensation carriers to obtain accident reports and medical records related to injury and disability. Uses best practices when representing the Funds. Compiles case file records in specified format, including arranging medical records in chronological sequence.
Interprets and applies relevant Plan rules and regulations to determine an applicant’s eligibility for a disability pension from the Funds.
Creates a comprehensive, detailed, and analytical written report summarizing the content of medical records and determining which records may support the causal link determination, which records may not and weighing all the evidence available. Applies high-level critical thinking skills to render a decision, based on an objective review of all clinical evidence available, as to whether a mine worker is disabled as a result of a mine accident and, therefore, may be entitled to a disability pension from the 1974 Pension Plan.
Conducts appeals of disability benefits denied after initial causal link review. Schedules pre-hearing conferences with appellants, attorneys, and other representatives. Explains the disability pension eligibility requirements and the appeals process. Reviews original causal link report to identify missing medical records that could be submitted for review. Prepares and sends post-hearing correspondence summaries of the pre-hearing conference to appellant and representatives.
For appeal hearings, reviews original file documentation and new evidence. Prepares a comprehensive, impartial report, summarizing all initial and new evidence. Determines whether to uphold the benefit denial or to approve the disability pension in accordance with established policies and procedures, serving as the Plan’s final eligibility determination.
Reviews denied disability pension files upon receipt of new evidence. Reconsiderations of prior denials may result in a brief response to the applicant or may require a complete causal link analysis and report.
Reviews employer challenges of approved disability pension and provides written response to the employer, summarizing the evidence in the file that supports the Plan’s decision, and referring cases to the Office of General Counsel as needed.
Works with the Office of General Counsel on denied disability pension cases that are in litigation. This may include advising attorneys on the particulars of a case, providing testimony, giving depositions, and/or completing additional analysis of cases remanded by the court.
Monitors continued eligibility for disability pension benefits. Reviews questionnaire responses, research case file documents, requests and reviews SSDI termination records, and determines if a pensioner remains qualified for disability pension benefits in accordance with Plan provisions and established policies and procedures. Documents case analysis and notifies pensioner of changes in their benefit eligibility.
Participates in a peer-review system for completed causal link analyses. Provides clear and constructive feedback to the peer regarding the content of the analysis and whether the decision reached by the peer is supported by the evidence.
Achieves defined individual goals regarding quantity of work. Works within the team to achieve group goals on turnaround of cases pending clinical review.
Contacts applicants, co-workers, and physicians, verbally or in writing, to obtain additional information necessary to determine eligibility for benefits.
Responds to inquiries, verbally or in writing, from applicants concerning the status of applications and the approval or denial of benefits.
Monitors and follows up on pending applications. Maintains current reference materials, manuals, etc., as required for performing assigned duties.
Uses computer system to input data, generate documents, and research cases.
Performs clinical review functions in the Medicare cost report audit, reviewing and analyzing claims data, medical records, and reports for completeness. Collaborates with consultants, health-care providers, and field staff to obtain medical records supporting claims processing procedure codes, medical necessity, and benefit payment.
Attends regular meetings of available and applicable professional organizations. Reads and evaluates professional literature on a continual basis, translates complex or technical information into a format that can be understood by others, and distributes as needed. Participates in and summarizes seminars in related fields.
Responsible for adhering to all Funds' policies and procedures adopted to comply with the Health Insurance Portability and Accountability Act (HIPAA) governing the privacy, security, and use of protected health information.
Travels as required to conduct Funds' business.
Performs other related duties as assigned.
QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and/or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE
Five years of experience as a Registered Nurse (RN) in a clinical environment is required, including experience in orthopedics in a primary or acute care setting. Two years of experience in narrative report writing that involved interpreting and analyzing complex regulations, policies, and procedures. Experience with data collection, medical records, and statistics is preferred. Legal experience with Workers’ Compensation or Social Security Disability Insurance claims is preferred.
TECHNICAL, BUSINESS, and INDUSTRY KNOWLEDGE
Advanced knowledge of human anatomy, pathophysiology, diagnoses and treatments, assessment, diagnostic testing, and lab results.
Ability to interpret and apply complex laws, rules, and regulations.
Ability to integrate complex, abstract multidisciplinary concepts into a well-written report.
Ability to organize workload, references, and manuals.
Ability to generate letters, reports, and/or basic spreadsheets and graphs using appropriate software. Ability to operate printers, scanners, and other peripheral devices.
COMMUNICATION SKILLS
Advanced - Ability to effectively present complex information or issues and respond to questions from groups such as managers, beneficiaries, outside vendors, or outside attorneys for purposes such as resolving conflict, negotiating critical transactions, or providing instructions and direction.
Advanced - Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures and manuals, and government regulations.
MATHEMATICAL SKILLS
Basic - Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
CERTIFICATES, LICENSES, REGISTRATIONS
Must maintain an active nursing license as a Registered Nurse (RN) or Nurse Practitioner.
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to stand and walk. Specific vision abilities required by this job include close vision, and ability to adjust focus.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.
PROBATIONARY PERIOD
90 standard workdays pursuant to Sections 5.06, 5.07 and 5.08 of the Collectively Bargained Agreement.
COMPLETE BACKGROUND CHECK REQUIRED.
