Clinical Risk Manager, C&F Stop Loss

Crum & Forster • Eatontown, NJ

10h • $67,900 - $127,600 • Remote

About The Position

The Clinical Risk Manager role utilizes a high level of experience and advanced knowledge regarding nursing, medical conditions, risk and prognoses as it relates to treatment plans and utilization of care. The Clinical Risk Manager provides accurate current and next year cost projections and savings opportunities to C&F. The Crum & Forster Accident & Health division (A&H) has offered a diverse portfolio of specialty insurance and reinsurance products nationwide since 2000. A&H places a strong focus on product development and creative distribution methods, along with excellent client service and support. In addition to its robust domestic portfolio, which spans both special risk and medical solutions, A&H works on an international basis through various partnerships. The A&H MBU takes a full-spectrum approach to designing and servicing a robust slate of products tailored to needs in Employer Stop Loss, Excess Medical, Life, and Ancillary and Supplemental benefits. The MBU recorded $1B in gross premium written at year-end 2025.

Requirements

• 5-10 years clinical experience with a current unrestricted licensure as a health professional (Registered Nurse) preferred
• 6+ years of reinsurance or insurance industry experience required
• Bachelor’s degree from an accredited university or equivalent experience required
• Strong PC skills including Excel, Word, Outlook
• Group medical, managed care, health insurance, stop loss or reinsurance experience required
• Strong knowledge of disease processes and treatment plans
• Expert analytical, investigative, and problem-solving skills with the ability to interpret complex medical and risk reports.
• Highly organized and adaptable, capable of managing multiple tasks with exceptional attention to detail in a fast-paced environment.
• Excellent interpersonal, oral, and written communication skills, with a strong focus on customer satisfaction and building rapport.
• Expert in negotiation, persuasion, and conflict resolution.
• Strong work ethic, personal accountability, and a commitment to producing high-quality, accurate work.
• A proactive, quick learner dedicated to getting the job done well.
• Proven ability to work effectively both independently and collaboratively within a team, with the capacity to mentor and guide junior staff.

Nice To Haves

• Current unrestricted licensure as a health professional (Registered Nurse) preferred

Responsibilities

• Review and analyze all data and documentation within existing systems and that provided by Underwriting including but not limited to diagnoses, procedures, case management notes, treatment plans, and comorbid conditions to assess validity of data and clinical risk.
• Identify clinical factors that may impact underwriting outcomes or financial exposure at a claimant and population health level for Underwriters to leverage in their rating of the group.
• Exercise independent clinical judgment to synthesize complex medical information into clear risk conclusions that support sound underwriting decisions.
• Support the development and implementation of clinical risk management strategies for high-cost, complex claims through strategic identification of cost-containment opportunities while reviewing all available data for MUW review.
• Cross-refer to cost containment when appropriate and participate in cost containment work as requested.
• Triage and prioritize requests for medical underwriting review based on business urgency, workload capacity, and alignment with underwriting and leadership priorities.
• Act as a strategic partner to underwriting by applying evidence-based criteria and sound clinical judgment to evaluate complex clinical and claims data to identify, quantify, and advise on significant risks, directly influencing underwriting strategy and decisions.
• Develop, maintain, and manage strong relationships with internal and external clients, Third-Party Administrators (TPAs), and vendors, championing exemplary customer service standards.
• Consult with clients and teams on submitted data for MUW, program development, quality improvement, and claim issues.
• Act as a point of contact for escalations and participate in calls with internal and external clients as needed.
• Ensure accurate entry, validation, and analysis of medical underwriting data within the claims system, maintaining high standards of data integrity.
• Perform accurate and thorough data scrubbing of reports for medical underwriting reviews, leveraging advanced skills in Excel and using AI tools and other available tools and resources.
• Request needed medical and claim data, collect said data and create reports in collaboration with Digital Transformation and/or IT teams to streamline departmental processes.
• Identify and resolve data gaps and discrepancies to ensure comprehensive data for cost containment interventions.
• Maintain clear records to support transparency and defensibility of underwriting decisions as it relates to clinical evaluation.
• Participate in quality assurance activities related to medical underwriting evaluations and engage in peer review and audit processes as requested.
• Serve as a primary subject matter expert, articulating complex clinical conditions, pharmaceuticals, and risk structures to diverse audiences, including executive leadership.
• Stay informed on emerging therapies, technologies, and medical conditions, disseminating key information to internal and external stakeholders.
• Provide concise, detailed, and clear assessments, projections, and recommendations, effectively explaining complex scenarios to both technical and non-technical audiences.
• Support and explore new methods and processes to increase efficiency and achieve individual and organizational goals.
• Ensure compliance with all company policies, procedures, and service standards.
• Document all activities and outcomes accurately and promptly, keeping management informed of progress and potential issues.
• Maintain proficiency with all IT systems utilized by the Clinical Risk Management team.

Benefits

• Flexible work arrangements.
• Competitive compensation package.
• Generous 401K employer match.
• Employee Stock Purchase plan with employer matching.
• Generous Paid Time Off.
• Excellent benefits that go beyond health, dental & vision.
• Wellness programs focus on your family’s complete wellness, including your physical and mental wellbeing.
• Tuition reimbursement, industry related certifications and professional training available.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior