Stop Loss Clinician

Position Overview

The Stop Loss Clinician will perform stop loss clinical risk assessments for the underwriting, claims, and actuary departments. This is accomplished by reviewing medical and claims information pertinent to individual claimants and providing estimates of ongoing risk for each individual based upon current, past and future treatment plans. This role will work with policyholders, third party administrators, BCBS plan medical management and outside vendors to manage medical and financial risk opportunities. This position reports to the Director of Clinical Solutions.

Clinical Claim Review

• Conducts medical necessity review of high risk medical/Rx claims, interact with plan medical management teams on transplant cases and high cost specialty drug cases, review claim history of individual claimants to advise the Underwriting Department and Claims department of potential catastrophic utilization.
• Apply working knowledge of care required for the premature neonate and their transition the home setting.
• Partner with outside specialty network vendors to identify potential areas for cost savings.

Care Management

• Assess and recommend effective claim cost containment and managed care vendors including preferred provider networks, alternative treatment strategies and delivery systems.
• Assess standard treatment plans by diagnosis including medical and surgical modalities for adult and pediatric claimants and rehabilitation programs.
• Review high-cost drug therapy for specific diagnoses including orphan drugs.
• Explore physician interventions including frequency of involvement and specialist interventions.
• Review current chemotherapy regimens for malignancies both primary and secondary.
• Explore common diagnoses that result in solid organ or hemopoietic transplants and a thorough understanding of the transplant process including the transplant evaluation, listing process, use of a vendor when warranted and the average wait time for all types of transplants.

Risk Management

• Create methods and models for anticipating loss activity in specialty reinsurance medical products, recommend reserving levels relating to large cases, accurately project costs of medical conditions, create reports on trends for product offerings, assist with tracking of risk on high cost claimants by utilizing Risk Management database to document current claimant clinical status, cost containment activities, vendors, etc.
• Review and interpret plan language in specific plan documents to assist with coverage determinations both in an underwriting and claim capacity.

Research and Development

• Identify relevant trends in new and emerging medical technologies through research of publications, networking in the health care delivery system, and attending relevant medical meetings.
• Gain awareness of new diagnoses, treatments, costs and industry trends.

Special Assignments

• Able to work on special projects as required.

Requirements

• List education, experience, competencies, travel and/or physical requirements required vs. preferred

• Education and Certifications: Active R.N. licensing required
• Experience: 2 years health insurance/reinsurance experience preferred with heavy emphasis on large case management preferred, 5 years of experience in an ambulatory or hospital setting required
• Competencies: Excellent verbal and written communication skills to support this endeavor required, Excellent organizational skills to meet established deadlines for clinical reviews required, Ability to utilize the current systems/applications for research and data retrieval required, Working knowledge of Microsoft Office Applications preferred
• Travel: Required, Travel up to 10% domestic

Compensation And Benefits

• Target base salary range for this full-time, salaried position is $100,700-$125,900
• Individual base pay depends on work location and additional factors such as experience, job-related skills, and relevant education or training.
• Total pay may include other forms of compensation.
• In addition, we offer competitive health, dental, 401k and wellness benefits beginning on the first day of the month following the first day of employment.
• Please ask your Talent Acquisition Specialist for more information about our total rewards package.