Clinical Risk Manager
Location
United States
Posted
18 days ago
Salary
Not specified
No structured requirement data.
Job Description
Role Description
As a Clinical Risk Manager, you'll perform medical risk analysis for our Traditional, Captive, and Managed Care business lines. The primary function is to review data to identify claimants and assess potential risks.
- Review detailed claim reports from a variety of sources to predict current and future claim costs
- Apply guidelines as appropriate to meet the goals of the company
- Research medical conditions and treatment options using available resources
- Document the medical review clearly, including an analysis of current clinical condition(s) and future annual claims projection
- Provide clinical guidance to other team members as needed
- Strategize and prioritize workload to achieve timelines and set goals for assigned work
- Make referrals to Clinical Cost Containment Services, and collaborate as needed to support their activities
- Stay informed of medical and drug trends, sharing information with team members
Qualifications
- Bachelor’s Degree in Nursing or related clinical field, or equivalent combination of education and experience
- 3+ years direct clinical experience, preferably in acute care
- 4+ years experience in medical underwriting or risk management
- Knowledge of medical coding and terminology (AHIP certification a plus)
- Knowledge of state and federal regulations related to underwriting
- Ability to interpret policies and procedures and communicate complex clinical topics effectively
- Ability to exercise sound judgment, initiative and discretion in a mature and sensitive manner
- Proficiency using Microsoft Office (Word, Excel, Outlook) or comparable software, and ability to learn and use complex systems
- Travel requirements 5%
Requirements
- Organizational and analytical skills, a demonstrated ability to manage multiple tasks simultaneously
- Ability to establish effective working relationships with coworkers and internal/external customers
- Strong verbal, written, interpersonal communication and customer service skills
- Ability to work independently with minimal direction and supervision
Benefits
- Competitive compensation
- Paid time off
- Comprehensive wellness benefits and programs
- Employer funded health savings account
- Profit sharing
- 401k
- Paid parental leave
- Employee stock purchase plan
- Tuition assistance and professional continuing education
Job Requirements
- Bachelor’s Degree in Nursing or related clinical field, or equivalent combination of education and experience
- 3+ years direct clinical experience, preferably in acute care
- 4+ years experience in medical underwriting or risk management
- Knowledge of medical coding and terminology (AHIP certification a plus)
- Knowledge of state and federal regulations related to underwriting
- Ability to interpret policies and procedures and communicate complex clinical topics effectively
- Ability to exercise sound judgment, initiative and discretion in a mature and sensitive manner
- Proficiency using Microsoft Office (Word, Excel, Outlook) or comparable software, and ability to learn and use complex systems
- Travel requirements 5%
- Organizational and analytical skills, a demonstrated ability to manage multiple tasks simultaneously
- Ability to establish effective working relationships with coworkers and internal/external customers
- Strong verbal, written, interpersonal communication and customer service skills
- Ability to work independently with minimal direction and supervision
Benefits
- Competitive compensation
- Paid time off
- Comprehensive wellness benefits and programs
- Employer funded health savings account
- Profit sharing
- 401k
- Paid parental leave
- Employee stock purchase plan
- Tuition assistance and professional continuing education
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