Stop Loss Nurse

Imagine360•,

1d•Remote

About The Position

Imagine360 is seeking a Stop Loss Nurse to join the team! The Stop Loss Nurse is responsible for identifying, monitoring, and managing high-cost and complex medical claims that may exceed stop-loss thresholds, supporting timely reporting, cost-containment strategies, and compliance with stop-loss policy requirements. This role focuses on early identification of large claimants, clinical review of high-cost drivers, and coordination with internal and external stakeholders, and support for timely carrier notification. The nurse collaborates with internal teams, TPAs, employers, and stop-loss carriers to manage large claims and minimize financial risk to ensure high quality and cost effective care for members.

Requirements

A nursing degree from an accredited college, university, or school of nursing.
2+ years of clinical experience (e.g., acute care, ICU, oncology, or case management)
2+ years experience in case management, utilization review, or managed care
Strong knowledge of medical terminology, healthcare delivery systems, and insurance processes
Active, unrestricted Registered Nurse (RN) license from an accredited college, university, or school of nursing.
Must maintain active, current, and unrestricted Registered Nurse license and CEU's as required by the State Board of Nursing.
Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization.

Nice To Haves

Experience with stop-loss insurance, large claims, or self-funded health plans
Certification in Case Management (CCM) or similar
Experience with high-cost claims such as transplants, oncology, or specialty drugs
Familiarity with claims systems and healthcare analytics
Must obtain Certified Case Manager (CCM) designation within 3 years of hire.

Responsibilities

Identify potential high-cost claims that may reach or exceed stop-loss thresholds through review of claims data, utilization trends, trigger diagnosis reports, and referral sources.
Review medical records, claims data, and treatment plans and utilization patterns to clinical and financial drivers identify high-cost claims.
Track and monitor ongoing claims approaching stop-loss thresholds and escalate as appropriate for reporting and intervention.
Review high cost and catastrophic medical claims to ensure policy compliance, and clinical appropriateness of services.
Evaluate complex cases and develop clinically informed summaries of current status, expected treatment trajectory, and projected future costs exposure for stop-loss reporting and underwriting support.
Analyze catastrophic and high acuity episodes of care to identify ongoing risk, cost drivers and opportunities for intervention.
Review potential claim notices, high-cost claimant reports, trigger diagnosis reports, and referrals from UM, CM, DM or brokers/clients to evaluate cost exposure and determine next steps.
Implement cost-containment strategies such as redirection to in-network or high-quality, cost-effective providers.
Collaborate with case management to manage high-cost therapies.
Support development of improved processes for identifying and flagging high cost claimants.
Collaborate with stop-loss carriers to submit timely notifications, updates, and required documentation
Prepare and manage large case reporting, including ongoing updates to stakeholders
Ensure compliance with stop-loss policy requirements and deadlines
Maintain accurate documentation of case activities, outcomes, and cost savings
Analyze claim trends , recurring high-cost drivers, and emerging patterns, and provide insights to leadership and clients.
Prepare recurring and adhoc reports on large claims and potential exposures.
Adhere to all regulatory requirements, HIPAA guidelines, and internal policies.
Participate in audits and quality improvement initiatives.
Maintain clinical documentation standards that support audit readiness, reporting accuracy and defensible case decision-making

Benefits

Multiple Health plan options
Company paid employee premiums for disability and life insurance
Parental Leave Policy
20 days PTO to start
10 Paid Holidays
Tuition reimbursement
401k Company contribution
Company paid Short & Long term Disability plus Life Insurance
Professional development initiatives / continuous learning opportunities
Opportunities to participate in and support the company's diversity and inclusion initiatives