Stop Loss Registered Nurse (W@H Anywhere)

BlueCross BlueShield of South Carolina

4d•Hybrid

About The Position

We are currently hiring for a Stop Loss Registered Nurse to join Pace Underwriters, a subsidiary of BlueCross BlueShield of South Carolina. In this role as a Stop Loss Registered Nurse, you will evaluate and manage catastrophic episodes of illness for underwriting and claims. Ensures that the insured is receiving the best medical care, but in the most cost-effective manner. Location: This position is full-time (40 hours/week) Monday-Friday, from 8:00am – 4:00pm CST and can be hybrid in Dallas, TX or fully remote. What You’ll Do: Facilitates cost estimates to the underwriters for new and renewal stop loss business. Consults with the underwriters on catastrophic episodes of illness. Provides case management oversight of managed care between the TPA and us. Review potential claim notices and excess claims received to determine setting reserves. Reviews potential claims notices from TPAs. Researches as necessary to evaluate cost containment and intervenes with the TPA.

Requirements

Associates in a job-related field
Graduate of Accredited School of Nursing
10 years, 5 years clinical plus 5 years medical management experience.
Working knowledge of word processing software.
Excellent verbal and written communication skills.
Ability to work independently, prioritize effectively, and make sound decisions.
Working knowledge of managed care and various forms of health care delivery systems.
Working knowledge of catastrophic claims cost, medical vendors, case management.
Demonstrated customer service, communication, and organizational skills.
Analytical or critical thinking skills.
Ability to handle confidential or sensitive information with discretion.
Microsoft Office.
Active RN licensure in state hired.

Nice To Haves

Previous experience with Case Management in an insurance environment.
Previous Stop Loss and/or Risk experience as a nurse.
10+ years as a medical staff nurse, experience working with a stop loss carrier and providing underwriting and claims with medical cost projects.

Responsibilities

Facilitates cost estimates to the underwriters for new and renewal stop loss business.
Consults with the underwriters on catastrophic episodes of illness.
Provides case management oversight of managed care between the TPA and us.
Review potential claim notices and excess claims received to determine setting reserves.
Reviews potential claims notices from TPAs.
Researches as necessary to evaluate cost containment and intervenes with the TPA.