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, developed a cost
mitigation strategy and worked 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 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