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About the Role
The Nurse Case Manager is a licensed Registered Nurse who serves as a clinical consultant, partnering with Claim Managers to provide specialized clinical expertise in the evaluation of Short-Term Disability (STD) and Long-Term Disability (LTD) claims. Leveraging expertise in medical and behavioral health conditions, the Nurse Case Manager conducts comprehensive reviews of clinical documentation, evaluates the severity and functional impact of reported conditions, and assesses whether the available medical evidence supports the identified functional restrictions or demonstrates functional impairment. The role collaborates with claims professionals, treating providers, internal physician consultants, and other clinical/vocational resources to support thorough, consistent, and timely claim evaluations while maintaining a holistic, function-focused approach.
Responsibilities
- Conduct comprehensive clinical reviews of STD and LTD claims involving medical, surgical, behavioral health, and co-occurring conditions.
- Integrate information from treating providers, customers, questionnaires, and other relevant sources to assess condition severity, functional impact, treatment response, expected recovery, comorbidities, and whether the available evidence supports identified restrictions and limitations or demonstrates functional impairment.
- Identify inconsistencies, gaps in clinical information, and areas requiring further clarification; formulate focused clinical questions; and recommend appropriate next steps, including requests for additional clinical information or records, provider or customer outreach, and physician or specialty review when warranted.
- Provide clear, objective, and well-supported clinical recommendations that support claim evaluation, assessment of functional status, and return-to-work considerations.
- Serve as a clinical resource by educating and consulting with Claim Managers while fostering collaborative relationships with internal business partners, physician consultants, and external healthcare providers.
- Document clinical findings, recommendations, and rationale in accordance with departmental standards, applicable policies, and regulatory requirements.
- Participate in quality assurance initiatives, departmental projects, training, and continuous process improvement activities.
Requirements
- Current, unrestricted Registered Nurse (RN) license in the state of residence and, where applicable, the state of employment.
- Three to five years of clinical nursing experience, including demonstrated experience in behavioral health.
- Demonstrated knowledge of medical and behavioral health diagnoses, treatment modalities, psychopharmacology, and recovery principles.
- Experience reviewing and analyzing medical records, behavioral health documentation, diagnostic findings, treatment plans, and other clinical information relevant to functional assessment.
- Proficiency with Microsoft Office applications, electronic documentation systems, and other technology platforms used to support clinical review and case management.
Skills
- Strong clinical judgment, critical thinking, and analytical skills, with the ability to synthesize complex clinical information and evaluate its impact on function.
- Strong written and verbal communication and consultation skills, with the ability to convey complex clinical information clearly to clinical and non-clinical audiences.
- Ability to work independently while collaborating effectively with Claim Managers, healthcare providers, and multidisciplinary partners.
- Strong organizational and time-management skills, with the ability to manage multiple priorities, communicate effectively during real-time interactions, document concurrently, and navigate multiple systems in a fast-paced environment.
- Continuous improvement mindset, with the ability to identify opportunities to enhance clinical review processes, quality, consistency, and efficiency.
- Digital fluency and adaptability, including the ability to effectively use and adopt emerging technologies and AI-enabled tools in accordance with organizational policies and standards.
- Commitment to continuous learning and professional development.
Location
- Fully Remote
Work Type
- Fully Remote
Experience Level
- Three to five years of clinical nursing experience
Education Level
- Bachelor of Science in Nursing (BSN)
Salary/Compensations
- $89,000-$115,000
Benefits
- Leave programs
- Adoption assistance
- Student loan repayment programs
About the Company
- Group Benefit Solutions delivers comprehensive insurance and absence management solutions for mid-size and large companies.
- At New York Life, our 180-year legacy of purpose and integrity fuels our future.
- As we evolve into a more technology-, data-, and AI-enabled organization, we remain grounded in the values that drive lasting impact.
- Our diverse business portfolio creates opportunities to make a difference across industries and communities—inviting bold thinking, collaborative problem-solving, and purpose-driven innovation.
- Here, you’ll find the rare balance of long-standing stability and forward momentum, supported by an inclusive team that honors tradition while embracing progress.
- As a Fortune 100 mutual company, we offer a place to grow your skills, contribute to meaningful work, and deliver solutions that matter.
- Your ideas drive what’s next, and your growth powers it.
Equal Opportunity
- At New York Life, fostering an inclusive workplace is fundamental to who we are and how we serve our communities.
- We have a longstanding commitment to creating an environment where individuals can contribute their best and succeed together.
- This foundation is rooted in our core values of humanity and integrity, ensuring that every employee feels valued and supported.
- By embracing a broad range of perspectives and experiences, we achieve greater success and fulfill our promise of providing financial security and peace of mind to families across all communities.
- Recognized as one of Fortune’s World’s Most Admired Companies, New York Life is committed to improving local communities through a culture of employee giving and volunteerism, supported by the Foundation.