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.