Clinical Risk Nurse

Description

The Clinical Risk Nurse at TPAC provides clinical expertise to support TPAC's underwriting and claims operations. This role evaluates medical risk, analyzes complex clinical data, and identifies cost drivers within the medical stop-loss portfolio.

• Evaluate medical records, clinical documentation, treatment plans, and diagnoses to assess risk severity, prognosis, and potential claim exposure for new business and renewal cases.
• Provide clinical insights and recommendations to underwriters on complex or high-exposure cases involving catastrophic, chronic, or specialty conditions.
• Analyze large claims and high-cost claimants, identifying trends in treatment, utilization, and cost drivers across the stop-loss portfolio.
• Develop and maintain clinical risk scoring models and reference tools to support consistent and accurate underwriting evaluations.
• Maintain awareness of emerging medical trends, new treatment protocols, pharmaceutical developments, and regulatory changes that may impact claims costs and stop-loss pricing.
• Collaborate with the Claims Department to review ongoing large claims, validate clinical appropriateness, and support reserving accuracy.
• Serve as a clinical subject matter expert for internal training, educating underwriting and claims staff on medical terminology, diagnoses, treatment pathways, and cost implications.
• Prepare clinical summaries and risk reports for underwriting leadership, reinsurers, and client presentations.
• Participate in TPA reviews and audits, evaluating the clinical accuracy and appropriateness of claims handling.
• Track, analyze, and report identified and realized claim savings, providing insights and recommendations to support organizational risk management and financial objectives.

Requirements

• Active Registered Nurse (RN) license required; Bachelor of Science in Nursing (BSN) preferred.
• 7+ years of clinical nursing experience, with a strong background in critical care, case management, utilization review, or risk management.
• 3+ years of experience in a stop-loss, reinsurance, health insurance, or managed care environment preferred.
• Strong knowledge of medical terminology, disease processes, treatment protocols, and pharmaceutical therapies.
• Familiarity with ICD-10, CPT, HCPCS coding systems and their application to claims and underwriting.
• Understanding of self-funded health plans, stop-loss insurance, and reinsurance structures.
• Excellent analytical skills with the ability to translate complex clinical information into financial risk assessments.
• Strong written and verbal communication skills with the ability to present clinical findings to non-clinical audiences.
• Detail-oriented with strong organizational skills and the ability to manage multiple cases and priorities simultaneously.
• Proficiency in Microsoft Office Suite (Outlook, Excel, Word, OneNote).
• CCM, COHN, CPHRM, or other relevant clinical or risk management certifications a plus.

Salary Range

$90,000 - $120,000