Clinical Assessment Nurse
Essential Duties and Responsibilities:
- Ensure effective risk management. Perform reviews, assessment of new business, and renewal large claims/disclosure to identify known and potential risk.
- Assist underwriters in the evaluation and assessment of clinical and claims data to identify and quantify known and potential risk through the provision of concise, detailed, and accurate reporting of data analysis findings, observations and recommendations to underwriting.
- Effectively explain complex clinical conditions to team.
- Develop and maintain strong client, TPA and vendor relationships.
- Consult with clients and TPA’s on case management issues, alternative levels of care, program development, quality improvement, claims issues and educational needs.
- Work with claim team to determine the need to impact, developed a cost mitigation strategy and worked with internal as well as external stakeholders to produce an effective clinical and financial outcome.
- Assist with medical necessity determinations and claim audits.
- Perform as needed: transplant and other complex /catastrophic care reviews including review of treatment plan for medical necessity/experimental treatment, appropriateness of setting and coordination of any necessary additional review with outside medical expert.
- Consult with internal and external clients on high cost claims and successfully engaged effective clinical risk management strategies.
- Determine need for extra contractual agreements and /or engagement of specialty resources and acts as a liaison until the claim is complete.
- Serve as a resource for claims and underwriting related to the risk management of A&H claims.
- Establish reserve recommendations and adjusted as needed and reviewed on a monthly basis.
- Build strong relationships with internal and external clients and communicated risk factors, resolved complex inquires and developed recommendations for continuous improvement.
- 5+ years of clinical and case management experience
- RN license required
- CCM preferred
- Bachelor's degree preferred
- Stop loss and reinsurance experience preferred
- Excellent written and oral communication skills
- Ability to multi-task and prioritize
- Team oriented yet able to work independently
- Ability to build and maintain strong professional relationships
- Proficiency with Excel, Word and spreadsheet analysis
Working Conditions/Physical Demands
Work environment characteristics and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Candidates who cannot perform some or all of these duties because of disabilities will nevertheless receive full consideration for the job based on their ability to perform essential duties and responsibilities.
While performing the duties of this job, the employee is not exposed to weather conditions and the noise level in the work environment is usually moderate. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stand and walk. The employee must frequently lift and/or move up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision, depth perception, and ability to adjust focus.
The above information in this job description has been designed to indicate the general nature and level of work performance by employees within this position. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.