Job Description

The Clinical Risk Manager RN is responsible for providing high quality case management and claims management consulting, including identification, assessment and projections of high-cost cases to assist in the underwriting process.

ESSENTIAL EDUCATION AND EXPERIENCE ASN or BSN in nursing licensed in the State of Residence; at least two (2) years of clinical experience, and at least two (2) years of stop loss or health payer experience.

SKILLS/COMPETENCIES REQUIREMENTS:

• Reviewing stop-loss cases, making recommendations on potential cost of care, including lasers recommendations.
• Use established guidelines when conducting stop-loss case reviews.
• Works with underwriting team to identify potential high-risk claimants in new business and renewal groups.
• Elicits support from sales and account management, and underwriting.
• Use reporting and risk identification tools on medical and pharmacy claims to assess risk.
• Assists in responding to inquiries from underwriting and sales for additional information on large claimants.
• Review of monthly TPA reporting on current business for reserving.
• Understanding of health and prescription costs.
• Understanding of health delivery systems and professionals.
• Understanding of disease life cycle, disease progression, expected health outcomes based on standard, accepted care management principles.
• Understanding of stop loss reporting tools and requirements preferred.
• Understanding of risk mitigation, high claimant detection, engagement and management preferred.
• Requires strong interpersonal skills with a demonstrated ability to work across divisions and with external stakeholders.
• Requires proficiency in the use of MS Office, AMS product suite, and ESL Office.

TRAVEL: Occasional travel may be required for meetings, conferences, or client visits. This includes compliance with all of the requirements of the localities and destinations, as well as transportation carrier requirements.