Job description
Principal Duties and Responsibilities
Ensure effective risk management. Perform reviews, assessment of new business, and renewal large claims/disclosure to identify known and potential risk.
Assist underwriters in the evaluation and assessment of clinical and claims data to identify and quantify known and potential risk through the provision of concise, detailed, and accurate reporting of data analysis findings, observations and recommendations to underwriting.
Effectively explain complex clinical conditions to team.
Develop and maintain strong client, TPA and vendor relationships.
Consult with clients and TPA’s on case management issues, alternative levels of care, program development, quality improvement, claims issues and educational needs.
Work with claim team to determine the need to impact, develop a cost mitigation strategy and work with internal as well as external stakeholders to produce an effective clinical and financial outcome.
Assist with medical necessity determinations and claim audits.
Perform as needed: transplant and other complex /catastrophic care reviews including review of treatment plan for medical necessity/experimental treatment, appropriateness of setting and coordination of any necessary additional review with outside medical expert.
Consult with internal and external clients on high cost claims and successfully engaged effective clinical risk management strategies.
Determine need for extra contractual agreements and /or engagement of specialty resources and acts as a liaison until the claim is complete.
Serve as a resource for claims and underwriting related to the risk management of A&H claims.
Establish reserve recommendations and adjusted as needed and reviewed on a monthly basis.
Build strong relationships with internal and external clients and communicated risk factors, resolved complex inquires and developed recommendations for continuous improvement.
Qualifications, Education and Experience Preferred
5+ years of clinical and case management experience
RN license required
CCM preferred
Bachelor's degree preferred
Stop loss and reinsurance experience preferred
Excellent written and oral communication skills
Ability to multi-task and prioritize
Team oriented yet able to work independently
Ability to build and maintain strong professional relationships
Proficiency with Excel, Word and spreadsheet analysis
Compensation & Benefits
The applicable base salary for this opportunity is $80,000 - $130000. The base pay offered will be determined by factors such as experience, skills, training, location, certifications, education, and any applicable minimum wage requirements. In addition to the base salary, this opportunity may be eligible for performance-based incentives. We are excited to offer a competitive total rewards package which includes health and welfare benefits, tuition and professional certification assistance, 401k savings, elective participation in the Employee Stock Purchase Program, paid time off, paid holidays, and child bonding leave, as well as other employee assistance.
Originally posted on Himalayas
Who can apply
Eligible countries: United States. Accepted UTC offsets: UTC-10, UTC-9, UTC-8, UTC-7, UTC-6, UTC-5, UTC+14. Review the full description for employer-specific work authorization, residency and schedule requirements.