Job Summary

This position is responsible for the review of case management notes, large claims reports and shock reporting for individuals and groups seeking stop loss insurance quotes and renewals. The position works closely with internal claim, clinical and case management teams to develop ongoing care and cost projections. The projections are then communicated to underwriting to help evaluate potential risk and associated costs.

Required Job Qualifications:

• Bachelor's degree in nursing is preferred with current state licensure and at least 3-5 years of clinical experience
• 2-4 years experience with Stop Loss products and clinical programs
• Strong analytical and problem solving skills
• Excellent organizational and time management skills, able to work independently with little supervision while handling numerous projects at once
• Excellent written/verbal communication skills, especially the ability to communicate effectively with underwriting staff
• Ability to complete cost projections on new and renewal business within 24-48 hours of receipt
• Documentation with clinical summary and estimated cost of care for each individual identified as at risk
• Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization
• Computer proficiency, specifically strong typing skills and Internet research skills, must have a clear understanding of Microsoft Word, Microsoft Office and Excel.

Preferred Job Qualifications:

• Clinical claims review and claims auditing experience
• Experience in managing complex or catastrophic health cases
• Specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, obstetric (low to high risk maternity management)
• Working toward or completion of CCM/CCP/CDE/MCG certification or Advanced degree
• Knowledge of Milliman Guidelines or similar clinical guidelines
• Knowledge of medical management policies and procedures

#LI-MW2

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting https://careers.hcsc.com/totalrewards.

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

Base Pay Range
$84,400.00 - $152,300.00

Exact compensation may vary based on skills, experience, and location.