Medicare Nurse - LVN or RN

Sedgwick Claims Management Services, Inc. Oakland, CA
Medicare Compliance Nurse (LVN/RN)


Providing both satisfying and challenging work along with a highly professional and friendly work atmosphere, Sedgwick has a strong commitment to its colleagues and its clients. If you are seeking a place where you can do great things for those whose lives you touch while maximizing your own career possibilities, Sedgwick is the place for you. As the largest and most innovative Third Party Administrator in the claims industry and the first and only TPA to receive both recognition as the Best TPA in America and the coveted Employer of Choice designation, we invite you to come be a part of our team and, "Claim Your Future."

PRIMARY PURPOSE: To prepare and draft Medicare Set-Asides (MSAs), Medical Cost Projects (MCPs) and related products.


* Prepares and drafts Medicare Set-Asides (MSAs), Medical Cost Projects (MCPs) and related products.

* Reviews medical claims and legal records; provides concise written reports depicting past medical care, current medical status and anticipated future medical care in MS Word and Excel format; creates reports documenting comprehensive and detailed medical summaries, evaluation of past treatment procedures, and prediction and accurate pricing of future treatment plan(s).

* Provides consulting services for assigned claims examiner and defense counsel related to Medicare and medical issues including, but not limited to, advising how to reduce an MSA, explanation of the MSA process, and discussion of specific medical procedures.

* Provides required training to examiners handling medical/Medicare issues related to general liability and workers' compensation.

* Creates and implements custom solutions to Medicare related problems including formulating solutions and communicating effectively verbally and in writing with healthcare providers, claims examiners and defense counsel to implement solutions.

* Identifies and resolves issues related to pricing MSAs and MCPs.

* Ensures quality, medical soundness, accuracy and timely delivery of MSA allocations and MCPs.

* Provides changes/updates to the MSA document/process as indicated within Medicare guidelines and industry standards to provide clients with the best MSA project available.

* Maintains appropriate file documentation.

* Maintains comprehensive knowledge of pricing trends for MSAs; incorporates trends into MSA and MCP reports.

* Maintains thorough knowledge of state laws to ensure proper compliance.


* Performs other duties as assigned.

* Supports the organization's quality program(s).

* Travels as required.


Education & Licensing

LVN or LPN and CPUR or equivalent certification required. Medicare Set-Aside Consultant Certified (MSCC) certification required. Bachelor's degree or equivalent preferred.


Five (5) years of related experience or equivalent combination of education and experience required to include two (2) years of MSA writing experience.

Skills & Knowledge

* Thorough knowledge of MSA creation and pricing

* Proficiency in medical research online and in written text

* Excellent oral and written communication skills

* PC literate, including Microsoft Office products

* Excellent mathematical skills

* Analytical and interpretive skills

* Strong organizational skills

* Ability to work in a team environment

* Ability to meet or exceed Performance Competencies


When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

NOTE: Credit security clearance, confirmed via a background credit check, is required for this position.

Sedgwick is an Equal Opportunity Employer

and a

Drug-Free Workplace

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