Clinical Risk Manager, C&F Stop Loss

Crum & Forster•Morristown, NJ

1d•$71,300 - $134,000•Remote

About The Position

The Clinical Risk Manager role uses advanced nursing and clinical expertise to assess complex medical conditions, risks, prognoses, treatment plans, and utilization of care. The position develops accurate current- and next-year cost projections and identifies savings opportunities while independently resolving complex clinical, claims, and data issues. It also serves as a resource to the Clinical Risk Management team by leading work efforts, mentoring team members, and supporting new employee onboarding and training. The role partners with underwriting to evaluate medical and claims data, identify and quantify clinical risks, and inform underwriting decisions. It works with internal and external clients, TPAs, vendors, and other teams on medical underwriting, program development, quality improvement, and claim issues. The position maintains accurate underwriting data and records, supports quality assurance and compliance, and communicates clinical assessments and recommendations to audiences ranging from technical teams to executive leadership. This is a remote role.

Requirements

6+ years of experience required, preferably in the reinsurance or insurance industry.
6–10 years of clinical experience; current unrestricted licensure as a health professional (Registered Nurse) preferred.
Bachelor’s degree from an accredited university or equivalent experience required.
Experience in group medical, managed care, health insurance, stop loss, or reinsurance required.
Strong knowledge of disease processes and treatment plans.
Strong PC skills, including Excel, Word, and Outlook.
Expert analytical, investigative, troubleshooting, and problem-solving skills, including the ability to interpret complex medical and risk reports.
Ability to manage multiple priorities independently with organization, adaptability, and exceptional attention to detail in a fast-paced environment.
Excellent interpersonal, oral, and written communication skills, with a focus on customer satisfaction and rapport-building.
Expertise in negotiation, persuasion, and conflict resolution.
Strong work ethic, personal accountability, and commitment to accurate, high-quality work.
Ability to work independently and collaboratively, lead work efforts, mentor junior staff, and support employee training and onboarding.

Nice To Haves

Current unrestricted Registered Nurse or other health-professional licensure.
Experience in the reinsurance or insurance industry.

Responsibilities

Review and analyze diagnoses, procedures, case management notes, treatment plans, comorbid conditions, and other available information to assess data validity and clinical risk.
Identify clinical factors that may affect underwriting outcomes or financial exposure at the claimant and population-health levels.
Synthesize complex medical information into clear risk conclusions to support underwriting decisions.
Support clinical risk management strategies for high-cost, complex claims and identify cost-containment opportunities.
Refer cases to cost containment when appropriate and participate in cost-containment work as requested.
Triage and prioritize medical underwriting requests based on urgency, workload, and business priorities.
Partner with underwriters to evaluate complex clinical and claims data, identify and quantify significant risks, and advise on underwriting strategy and decisions.
Develop and maintain relationships with internal and external clients, TPAs, and vendors, and provide exemplary customer service.
Consult with clients and teams on data submitted for medical underwriting, program development, quality improvement, and claim issues.
Serve as an escalation contact and participate in calls with internal and external clients as needed.
Enter, validate, and analyze medical underwriting data in the claims system, maintaining data integrity.
Scrub medical underwriting reports using Excel, AI tools, and other available resources.
Request and collect medical and claim data and collaborate with Digital Transformation and IT teams to create reports and streamline processes.
Identify and resolve data gaps and discrepancies relevant to cost-containment interventions.
Maintain clear records supporting transparency and defensibility of clinical evaluations and underwriting decisions.
Participate in quality assurance, peer review, and audit processes as requested.
Serve as a subject matter expert on clinical conditions, pharmaceuticals, and risk structures; share information about emerging therapies, technologies, and medical conditions.
Communicate clear assessments, projections, and recommendations to technical and non-technical audiences, including executive leadership.
Support process improvements and methods that increase efficiency and help achieve organizational goals.
Comply with company policies, procedures, and service standards; document activities and outcomes promptly and keep management informed of progress and issues.
Maintain proficiency with IT systems used by the Clinical Risk Management team.
Lead work efforts, mentor team members, and support onboarding and training of new employees.

Benefits

Flexible work arrangements.
Competitive compensation package.
Generous 401K employer match.
Employee Stock Purchase plan with employer matching.
Generous Paid Time Off.
Health, dental, and vision benefits.
Wellness programs supporting physical and mental wellbeing for employees and their families.
Tuition reimbursement.
Industry-related certifications and professional training.
Discretionary equity-based compensation and/or performance-based variable pay programs may be available.
Matching donation program and volunteer opportunities.