Clinical Risk Specialist RN

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.