Job description
This is a remote position.
The Role
Your clinical assessments will directly influence millions of dollars in stop-loss decisions. When a case gets complex, expensive, or both — you are the person underwriters, TPAs, and consortium employers rely on. This is notcarecoordination orutilizationreview. It is clinical risk intelligence, and the financial stakes are real.
You will work at the intersection of claims, underwriting, and member outcomes. Your written assessments inform attachment points and renewal strategy. Your advocacy can remove or reduce lasers at renewal. Your early identification of catastrophic case trajectories protects employers from exposure theydidn'tsee coming. This role hasconsequence.
WhatYou’llDo
Clinical Risk Review
Review stop-loss claim notices and claimant medical records toidentifyhigh-cost trajectories before excess loss is incurred, protecting consortium employers from avoidable exposure
Produce written clinical assessments that translate prognosis and treatment trajectory into actionable underwriting guidance, including recommendations on self-funded attachment points and stop-loss limits
Flag catastrophic case exposure to leadership as soon asidentified, with reserve recommendations and clear risk narrative. Nothing catches us or our employers off guard
Stop-Loss & Renewal Advocacy
Advocate directly with stop-loss carrier partners for laser reduction or removal at renewal, using documentedprognosisdata, case management activity, and clinical evidence to support your position.
Partner with TPAs and external case managers as Virtue Health's clinical resource on complex and catastrophic cases,facilitatingbetter financial and clinical outcomes for claimants and employers alike.
Program Development
Deliver clinical education to internal staff, TPA partners, and the adviser network on high-cost diagnoses, pharmaceutical cost trends, and emerging clinical developments that affect claims exposure
Evaluatenew costcontainment vendors, specialty case management resources, and preferred provider options to strengthen the tools available to consortium employers
Drive continuous improvement in Virtue Health's cost containment program,this function is early-stageand you will havesignificant influenceover how it is built
Drive continuous improvement in Virtue Health’s cost containment program by evaluating new vendor partners, clinical tools, and care management resources that strengthen outcomes across the consortium
What You Bring
Must-Haves
5+ years of direct clinical nursing experience in an acute care setting such as ICU, oncology, transplant, surgical, or complex chronic disease management
Active, unencumbered RN license; compact state license strongly preferred given the remote and multi-state nature of the work
3+ years of case management,utilizationreview, or payer-side experience at a TPA, HMO, PPO, stop-loss carrier, or reinsurance firm
Working knowledge of how stop-loss insurance, self-funded health plans, and TPA operations work, you can hold your own in a conversation with an underwriter
CCM (Certified Case Manager) certification
Great to Have
Direct experience working with a stop-loss carrier, consortium, or reinsurance firm in a clinical review or medical risk capacity
Experience in laser advocacy, stop-loss renewal support, or clinical prognosis documentation for underwriting purposes
Deep familiarity with high-cost pharmaceutical trends, specialty and gene therapy drugs, and their downstream claims impact on self-funded plans
BSN or higher
You’rea Fit If You…
Thrive in a fast-paced environment and treat ambiguity as an opportunity, not a roadblock.
Hold yourself to a high standard and then raise it.
Own your results. No excuses, nohand-holding, just solutions.
Operate with integrity in everything you do, even when no one is watching.
Show up consistently, follow through on every commitment, and do it well.
Push yourself and the people around you to be better and mean it.
Take feedback as fuel, not criticism.You’realways learning.
Get genuinely energized by turning clinical knowledge into financial outcomes and see cost containment as a form of advocacy for employers and the people they cover.
Compensation & Benefits
We pay for performance and reward people who step up. In addition to your base,you’reeligible for:
Performance bonus: up to 10% of base tied to measurable cost containment outcomes (MBO)
Health and Dental insurance
Life, short-term and long-term disability insurance
401(k)
PTO
Travel:Up to 10% for consortium events, TPA partner visits, and industry conferences
Our Hiring Process
Here’show our process typically runs. Steps may vary depending on the role.
Pre-Screening Assessment
Screening
Assessments (Cultural fit and, depending on the role, a skills assessment)
Interview
Interview
Offer
Ready?Let’sGo.
Join us. Build something that matters.
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.