Stop Loss Nurse

About the role

In this role you will evaluate stop loss claimant details on incumbent and prospective business to evaluate potential medical and prescription treatment plan(s) and associated costs to provide estimated risk for Underwriting and Cost Containment purposes.

What you will do

• Review policyholder data to identify claimants with catastrophic care needs and assess medical and claim information to calculate potential risk
• Provide written claimant assessments within established timeframes to the Underwriters/RGM's for use when establishing rates for new and renewal business
• Review potential stop loss claim notices to identify case management and cost containment opportunities to reduce potential excess loss claim expenses
• Advise management and underwriters of potential claims involving significant risk as needed
• Work with Third Party Administrators (TPAs) and external Case Managers using medical and claims management resources to facilitate clinical and financial outcomes for claimants with complex and catastrophic medical conditions
• Maintain current claimant clinical status, cost containment activities
• Act as a resource for internal and external customers:
  • Identify and support training opportunities for Claims, Underwriting, Sales, and TPA when knowledge gaps are identified
  • Provide clinical opinion from knowledge, experience and/or research to claims examiners and underwriters as needed
  • Assess and recommend effective claim cost containment and managed care vendors including preferred provider networks in assigned geographical region
  • Identify geographical healthcare trends in assigned marketplace for potential solution implementation. Keep Underwriting and Sales appraised of any trends that pose risk
• Maintain CE hours to meet State RN Licensure and CCM (or Industry) certification renewal requirements
• Author educational articles to provide industry updates to internal contacts

Requirement

• BS in Nursing - Current on Licensure
• Minimum 5 Years experience as a Stop Loss Nurse both evaluating risk and managing cost containment
• Experience in evaluating large amounts of data to determine risk
• Excellent communication skills, working with Carrier, Broker, Group, Member and Third-Party Administrator
• Willing to dive into activities, assist with streamline processes to drive savings

Current Openings for Stop Loss Nurse Jobs at Health in Tech