Clinical Risk Management Leader

Gallagher•Houston, TX

About The Position

This role will serve as a founding functional leader responsible for building and scaling the Clinical Risk Intelligence & Cost Containment capability. The role reports to the Chief Medical Officer, who will provide clinical, financial, and strategic oversight of the new product. The individual assuming this position will be responsible for designing and operationalizing program analytics, clinician reviews, reporting, and strategic partnerships (e.g., stop-loss carrier relationships). The individual will translate these inputs into an end-to-end operating capability for clinical risk intelligence, enabling the identification, analysis, and mitigation of high-cost healthcare exposures through data-driven insights, clinical analytics, high-cost claimant related benefit design, and reimbursement and utilization strategies. They will provide day-to-day oversight of team member activities and have responsibility for the product financials. They will also serve as a senior subject matter expert in internal and external discussions (including client and prospect meetings), translating complex clinical and financial data into actionable insights that improve healthcare cost performance, enhance risk identification, and support underwriting and client decision-making. The product will be established in a launch phase environment, initially supporting early pilots and client implementations, with a defined roadmap toward a repeatable, scalable, and enterprise-aligned capability to serve existing Gallagher Benefits Solutions clients as well as other entities.

Requirements

Degree from an applicable school of training/ nursing
A minimum of 5 years clinical experience in an acute care setting required.
Active license or equivalent within the state of practice or states in which CM is performed.

Responsibilities

Functional Build-Out & Operating Model Development: Liaison with internal Gallagher resources to develop product infrastructure (e.g., financial tracking, clinical database, reporting) and communication materials (product name, collateral, etc.). Define operating model, governance structure, workflows, and delivery cadence for the product. Develop minimum viable capabilities required to support early-stage pilots and client engagements. Design scalable methodologies that enable transition from manual analysis to standardized, repeatable delivery, including potential partner vetting. Build foundational infrastructure to support future expansion and increased automation.
Clinical Risk & High-Cost Claim Analysis: Lead structured analysis of high-cost and catastrophic claims to identify risk drivers and cost containment opportunities. Evaluate complex clinical scenarios including oncology, specialty pharmacy, transplant, NICU, chronic disease, and emerging therapies. Develop actionable recommendations balancing clinical appropriateness, member experience, and financial outcomes. Support implementation of targeted interventions in collaboration with internal and external stakeholders.
Predictive Analytics & Data Enablement: Partner with data and technical teams to define requirements for clinical and claims data integration, normalization, and reporting. Develop and refine predictive models, trigger logic, and analytical frameworks to identify high-risk claims earlier in the lifecycle. Translate fragmented healthcare data into structured, decision-ready insights for underwriting, care management, and client reporting. Advance the capability toward more scalable, automated, and standardized analytics over time.
Healthcare Cost Optimization & Reimbursement Strategy: Identify opportunities to reduce healthcare spend across reimbursement integrity, specialty pharmacy, site-of-care optimization, coding accuracy, and utilization trends. Support resolution of high-dollar claim disputes and reimbursement issues. Develop repeatable cost containment approaches and playbooks for broader deployment across clients. Identify systemic cost leakage patterns and translate findings into actionable interventions.
Stop-Loss, Underwriting & Risk Collaboration: Partner with employers, underwriting, actuarial, and stop-loss stakeholders to integrate clinical intelligence into risk assessment and pricing strategies. Support evaluation of claimant severity, emerging risk trajectories, and renewal and laser considerations. Enhance risk assessment methodologies through clinical insight and predictive indicators. Contribute to development of decision-support tools for underwriting and risk selection.
Client Delivery & Stakeholder Engagement: Along with the CMO, serve as senior clinical and financial subject matter expert in client and prospect meetings, pilots, and early-stage implementations. Translate analytical outputs into clear, executive-level insights for employers, consultants, and carrier partners. Support commercial teams in articulating value propositions and capability differentiation. Incorporate client feedback into continuous refinement of analytical and operational approaches.
Team Building & Functional Leadership: Recruit, build, and lead the initial clinical risk intelligence & cost strategy team. Define roles, competencies, and organizational structure aligned to divisional growth plans. Establish performance standards, analytical rigor, and operating cadence for the function. Develop leadership depth required to support future scaling of the product.