Senior Associate, Nurse Case Manager

Group Benefit Solutions delivers comprehensive insurance and absence management solutions for mid-size and large companies. Our work fosters a healthier, happier and more secure workforce, contributing to New York Life’s legacy of being there when we’re needed most. Here, you’ll design, implement and support these solutions directly impacting customers’ lives. At our core, we provide financial security and peace of mind to people through our absence, accident, disability, voluntary benefits and life insurance solutions.

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.

• 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.

• 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.

• Bachelor of Science in Nursing (BSN).
• Experience in disability insurance,…