Clinical Consultant, Accident & Health

Skyward Specialty

9d•$80,000 - $130,000

About The Position

This role involves ensuring effective risk management within the Accident & Health sector. The Clinical Consultant will perform reviews and assessments of new business and large claims to identify risks. They will also assist underwriters by analyzing clinical and claims data, providing detailed reports with findings, observations, and recommendations. The position requires explaining complex clinical conditions to the team, developing and maintaining strong client and vendor relationships, and consulting on various case management issues, program development, and quality improvement. The consultant will work with claims teams to develop cost mitigation strategies and ensure effective clinical and financial outcomes. Responsibilities also include assisting with medical necessity determinations, claim audits, and performing complex care reviews for catastrophic cases. The role involves consulting on high-cost claims, determining the need for extra contractual agreements or specialty resources, and serving as a resource for risk management of A&H claims. Establishing and adjusting reserve recommendations is also a key duty, along with building relationships and communicating risk factors to internal and external clients.

Requirements

5+ years of clinical and case management experience
RN license required
Excellent written and oral communication skills
Ability to multi-task and prioritize
Team oriented yet able to work independently
Ability to build and maintain strong professional relationships
Proficiency with Excel, Word and spreadsheet analysis

Nice To Haves

CCM preferred
Bachelor's degree preferred
Stop loss and reinsurance experience preferred

Responsibilities

Ensure effective risk management through reviews and assessments of new business and large claims.
Assist underwriters in evaluating clinical and claims data to identify and quantify risk.
Provide concise, detailed, and accurate reporting of data analysis findings, observations, and recommendations to underwriting.
Explain complex clinical conditions to the team.
Develop and maintain strong client, TPA, and vendor relationships.
Consult with clients and TPAs on case management issues, alternative levels of care, program development, quality improvement, claims issues, and educational needs.
Work with the claims team to determine the need for impact, develop cost mitigation strategies, and collaborate with stakeholders for effective clinical and financial outcomes.
Assist with medical necessity determinations and claim audits.
Perform transplant and other complex/catastrophic care reviews, including treatment plan review for medical necessity/experimental treatment, appropriateness of setting, and coordination of additional review with outside medical experts.
Consult with internal and external clients on high-cost claims and implement effective clinical risk management strategies.
Determine the need for extra contractual agreements and/or engagement of specialty resources, acting as a liaison until the claim is complete.
Serve as a resource for claims and underwriting related to the risk management of A&H claims.
Establish and adjust reserve recommendations on a monthly basis.
Build strong relationships with internal and external clients, communicate risk factors, resolve complex inquiries, and develop recommendations for continuous improvement.