Clinical Risk Analyst

Tokio Marine HCC

4d•$70,700 - $106,100•Remote

About The Position

Under limited supervision, reviews transplant and neonate cases and implements cost containment measures. Participates in medical underwriting, vendor monitoring and education.

Requirements

Registered Nurse, Associates degree in Nursing(ADN), or Bachelor's degree in Nursing (BSN)
Strong medical knowledge, including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPPA
Possess and have the ability to apply knowledge of principles, practices, and procedures
Solid written and verbal communication skills with an emphasis on confidentiality, tact, and diplomacy
Advanced organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneously
Knowledgeable of industry changes, legal updates, and technical developments related to the applicable area of the Company’s business to proactively respond to changing business conditions

Responsibilities

Gather in-depth information from sources (physicians, providers, utilization review [UR] vendors, claims, and medical records) about an individual's physical, medical, and psychosocial status. This information will be used in conjunction with the primary case manager to develop a comprehensive case management plan.
Determine specific objectives and time-specific actions designed to meet the claimant's needs identified in the assessment phase. At the reinsurance level, this also includes a review of available benefits.
Organize, secure, and integrate the available resources in order to accomplish the objectives of the case plan.
Gather relevant information on an ongoing basis to determine the plan's effectiveness, measure cost benefits, and set accurate reserves.
Act as support for renewal underwriting. This includes, but is not limited to, assessing the severity code on ongoing claims, adjusting reserves for accuracy, evaluating new referrals if effective within sixty days of notice, and assigning recommended specifics, if requested.
Educate internal staff and third-party administrators about Stop Loss Group's Specialty Claims Unit services.
Serve as a clinical resource for other Medical Underwriting staff based on clinical specialty in transplants.
Complete projects and other relevant duties as requested.

Benefits

Competitive salary and comprehensive benefit package
Strong learning culture with ongoing development opportunities
Opportunities for growth and career advancement
Comprehensive medical, vision, and dental coverage, with eligibility beginning on your first day of employment
Basic life and disability insurance
401(k) plan with 6% company match
20 days of PTO, two floating holidays, approximately 11 paid holidays, and volunteer time off
Paid parental leave
Access to our award-winning wellness program, including mental health services, fitness network membership, and a complimentary Headspace subscription
Student loan matching program
Employee discount program
An opportunity to do meaningful work and love what you do