Job Description

This is a clinical nurse position in our Risk Management Team within NAS Specialty Healthcare. Provides expert consultative services to the Employer Stop-Loss and HMO/PEI underwriting teams. Performs medical reviews to evaluate risks in collaboration with underwriting. Provides recommendations for lasered, at risk and excluded individuals as part of the group evaluation process. Provides concise documentation of these recommendations, along with ongoing monthly reviews as needed.

Responsibilities:

• High-Cost Claim Review: Evaluate catastrophic or high-dollar conditions and claims and review potential claim notices from TPAs (Third-Party Administrators).
• Review a variety of claim reports, such as paid claim detail, denied/pended and Rx reports, along with precertification and case management notes.
• Analyze claims, costs and clinical information to identify high risk individuals and assess financial costs for the upcoming policy term for claimants who may exceed a group’s specific deductible.
• Risk Evaluation and Underwriting Support: Provide clinical expertise to underwriting teams for new and renewal Employer Stop-Loss and HMO/PEI business, identifying, and assessing risks associated with specific diseases or conditions.
• Cost Containment: Review and monitor treatment, identifying areas in which costs may be mitigated (e.g., transplants).
• Document a medical review summary with specific analysis of a claimant’s clinical condition and annual claims projection with financial risk projection.
• Provide clinical guidance and collaboration with other team members as needed.
• Review Plan Documents for gap concerns and Amendments for stop loss impact.
• May lead projects or project steps within a broader project or have accountability for ongoing activities or objectives.

Qualifications

Licensure: Active, unrestricted RN license in state of residence.

Experience Minimum of 5 years of clinical experience with at least 3 years of clinical experience in a high-complexity medical area (examples ER, ICU, Oncology, NICU, Transplant). Prior stop loss or HMO/PEI carrier experience required for senior position.

Skills:

• Ability to multi-task, manage multiple medical review requests with little to no administrative support.
• Strong analytical, critical thinking and communication skills to explain medical conditions and treatment to underwriters.
• Fully effective interpersonal, writing and other communication skills, required to develop and maintain relationships with underwriters, peers, and colleagues.
• Working knowledge of healthcare delivery systems.
• Knowledge of stop loss, HMO/PEI reporting, plan language and contractual requirements.
• Detail-oriented with exceptional organizational skills.
• Proficiency in Microsoft Office products with intermediate to advanced level Excel skills required.

About Us

Pay Philosophy: The typical starting salary range for this role is determined by a number of factors including skills, experience, education, certifications and location. The full salary range for this role reflects the competitive labor market value for all employees in these positions across the national market and provides an opportunity to progress as employees grow and develop within the role. Some roles at Liberty Mutual have a corresponding compensation plan which may include commission and/or bonus earnings at rates that vary based on multiple factors set forth in the compensation plan for the role.At Liberty Mutual, our goal is to create a workplace where everyone feels valued, supported, and can thrive. We build an environment that welcomes a wide range of perspectives and experiences, with inclusion embedded in every aspect of our culture and reflected in everyday interactions. This comes to life through comprehensive benefits, workplace flexibility, professional development opportunities, and a host of opportunities provided through our Employee Resource Groups. Each employee plays a role in creating our inclusive culture, which supports every individual to do their best work. Together, we cultivate a community where everyone can make a meaningful impact for our business, our customers, and the communities we serve. We value your hard work, integrity and commitment to make things better, and we put people first by offering you benefits that support your life and well-being. To learn more about our benefit offerings please visit: https://www.libertymutualgroup.com/about-lm/careers/benefitsLiberty Mutual is an equal opportunity employer. We will not tolerate discrimination on the basis of race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, veteran's status, pregnancy, genetic information or on any basis prohibited by federal, state or local law. Fair Chance Notices

• California
• Los Angeles Incorporated
• Los Angeles Unincorporated
• Philadelphia
• San Francisco