The Clinical Risk Specialist 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 (Connexure/David Young).
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.
