Senior Medical Specialist- Stop Loss/HMO

Provides expert consultative services to the Employer Stop-Loss and HMO/PEI underwriting teams. Performs medical reviews to evaluate risks in collaboration with underwriting. Provides recommendations for lasered, at risk and excluded individuals as part of the group evaluation process. Provides concise documentation of these recommendations, along with ongoing monthly reviews as needed. High-Cost Claim Review: Evaluate catastrophic or high-dollar conditions and claims and review potential claim notices from TPAs (Third-Party Administrators). Review a variety of claim reports, such as paid claim detail, denied/pended and Rx reports, along with precertification and case management notes. Analyze claims, costs and clinical information to identify high risk individuals and assess financial costs for the upcoming policy term for claimants who may exceed a group's specific deductible. Risk Evaluation and Underwriting Support: Provide clinical expertise to underwriting teams for new and renewal Employer Stop-Loss and HMO/PEI business, identifying, and assessing risks associated with specific diseases or conditions. Cost Containment: Review and monitor treatment, identifying areas in which costs may be mitigated (e.g., transplants). Document a medical review summary with specific analysis of a claimant's clinical condition and annual claims projection with financial risk projection. Provide clinical guidance and collaboration with other team members as needed. Review Plan Documents for gap concerns and Amendments for stop loss impact. May lead projects or project steps within a broader project or have accountability for ongoing activities or objectives. Licensure: Active, unrestricted RN license in state of residence. Experience: Minimum of 5 years of clinical experience with at least 3 years of clinical experience in a high-complexity medical area (examples ER, ICU, Oncology, NICU, Transplant). Prior stop loss or HMO/PEI carrier experience required for senior position. Ability to multi-task, manage multiple medical review requests with little to no administrative support. Strong analytical, critical thinking and communication skills to explain medical conditions and treatment to underwriters. Fully effective interpersonal, writing and other communication skills, required to develop and maintain relationships with underwriters, peers, and colleagues. Working knowledge of healthcare delivery systems. Knowledge of stop loss, HMO/PEI reporting, plan language and contractual requirements. Detail-oriented with exceptional organizational skills. Proficiency in Microsoft Office products with intermediate to advanced level Excel skills required.