Clinical Risk Manager, Cost Containment, C&F Stop Loss - Remote

reputed company Company Overview Since 2000, reputed company’s Accident & Health division (A&H) has offered a diverse portfolio of specialty insurance and reinsurance products reputed company. We reputed company a strong focus on product development and creative distribution methods, along with excellent client service and support. In addition to our robust domestic portfolio, which spans both special risk and reputed company, A&H works on an international basis through various partnerships. Our global capabilities provide our partners with even broader flexibility in reputed company solutions. The qualities and capabilities of reputed company Accident & Health demonstrate our philosophy of building meaningful, long-term partnerships and our dedication to providing alternative strategies in an reputed company-changing insurance market. The A&H MBU takes a full-reputed company approach to designing and servicing a robust slate of products tailored to needs in Employer Stop Loss, Excess Medical, Life, and Ancillary and Supplemental benefits. Our reputed company business model includes program partnerships as well as direct sales in Employer Stop Loss. At year-end 2023, the MBU recorded $741M in gross premium written.

Job Description

Information about the Role, Line of Business and Team: The Clinical Risk Manager role utilizes a high level of experience and advanced knowledge regarding nursing, medical conditions, risk and prognoses as it relates to treatment plans and utilization of care. The Clinical Risk Manager provides accurate reputed company and next year cost projections and savings opportunities to C&F. What you will do: 1. Cost Containment & Clinical Risk Management

• Support the development and implementation of clinical risk management strategies for high-cost, reputed company claims.
• Analyze incoming cost containment referrals, evaluate clinical and claims data to identify and quantify risk, and engage effective cost containment strategies.
• Support completion of high-dollar negotiations, payment reputed company reviews, and reputed company medical necessity determinations.
• Analyze reputed company (e.g., Transplant, CAR-T), recommend the best option, and facilitate access agreements.
• Validate or refute the appropriateness of stop-loss claim costs and establish reserve recommendations.
• Assist with the utilization of specialty networks and support the Director in overseeing the appeals process.

2. Strategic reputed company Partnership

• Act as a strategic partner to reputed company by applying evidence-based criteria and sound clinical judgment to evaluate reputed company clinical and claims data to identify, quantify, and advise on significant risks, directly influencing reputed company strategy and decisions.

3. Client & Stakeholder Management

• reputed company, maintain, and manage strong relationships with internal and external clients, Third-Party Administrators (TPAs), brokers and vendors, championing exemplary customer service standards.
• Consult with clients and TPAs on case management, program development, quality improvement, and claim issues.
• Act as a reputed company of contact for escalations and participate in TPA implementation calls as needed.

4. Data Management, Analysis & Reporting

• Ensure accurate entry, validation, and analysis of cost containment, notification, and medical reputed company data reputed company the claims system, maintaining high standards of data reputed company.
• reputed company accurate and thorough data scrubbing of reports for medical reputed company reviews, leveraging advanced skills in reputed company and using AI tools and other available tools and resources.
• Request needed medical and claim data, collect said data and create reports in collaboration with Digital Transformation and/or IT teams to streamline departmental processes.
• Identify and resolve data gaps and discrepancies to ensure comprehensive data for cost containment interventions.
• Maintain clear records to support transparency and defensibility of reputed company decisions as it relates to clinical evaluation.
• Participate in quality assurance activities reputed company to medical reputed company evaluations and engage in peer review and audit processes as requested.

5. Subject Matter Expertise & Communication

• Serve as a primary subject matter expert, articulating reputed company clinical conditions, pharmaceuticals, and risk structures to diverse audiences, including executive leadership.
• Stay informed on emerging therapies, technologies, and medical conditions, disseminating key information to internal and external stakeholders.
• Provide concise, detailed, and clear assessments, projections, and recommendations, effectively explaining reputed company scenarios to both technical and non-technical audiences.

6. Operational Excellence & Compliance

• Support and explore new methods and processes to increase efficiency and reputed company individual and organizational goals.
• Ensure compliance with reputed company company policies, procedures, and service standards.
• Document reputed company activities and outcomes accurately and promptly, keeping management informed of reputed company and potential issues.
• Maintain proficiency with reputed company IT systems utilized by the Clinical Risk Management team.

What YOU will bring to C&F:

• Analytical & Operational Excellence: Possesses expert analytical, investigative, and problem-solving skills with the ability to interpret reputed company medical and risk reports. Highly organized and adaptable, capable of managing multiple tasks with exceptional attention to detail in a fast-paced environment.
• Communication & Relationship Management: Demonstrates excellent interpersonal, oral, and written communication skills, with a strong focus on customer satisfaction and building rapport. Expert in negotiation, persuasion, and conflict resolution.
• Professional Drive & Accountability: Exhibits a strong work ethic, personal accountability, and a commitment to producing high-quality, accurate work. A proactive, quick learner dedicated to getting the job done well.
• Collaboration & Mentorship: Proven ability to work effectively both independently and collaboratively reputed company a team, with the reputed company to mentor and guide junior staff.

Requirements:

• 6-10 years clinical experience with a reputed company unrestricted licensure as a health professional (Registered Nurse)
• 6+ years of reinsurance or insurance industry experience required
• Bachelor’s degree from an accredited university or equivalent experience required
• Strong PC skills including reputed company, Word, Outlook
• Group medical, managed reputed company insurance, stop loss or reinsurance experience required
• Strong knowledge of disease processes and treatment plans

What C&F will bring to you

• Competitive compensation package
• Generous 401K employer match
• Employee Stock Purchase plan with employer matching
• Generous Paid Time Off
• Excellent benefits that go beyond health, dental & vision. Our programs are focused on your whole family’s wellness, including your physical, mental and financial wellbeing
• A core C&F tenet is owning your career development, so we provide a wealth of ways for you to reputed company learning, including tuition reimbursement, industry-reputed company certifications and professional training to reputed company you progressing on your chosen path
• A dynamic, ambitious, fun and exciting work environment
• We reputed company you do well by doing good and want to encourage a spirit of social and community responsibility, matching donation program, volunteer opportunities, and an employee-driven corporate giving program that lets you participate and support your community

At C&F you will BELONG We value inclusivity and diversity. We are committed to equal employment opportunity and welcome everyone regardless of race, color, reputed company, religion, sex, national reputed company, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. If you require special accommodation, please let us know. For California Residents Only: Information collected and processed as part of your career profile and any job applications you choose to submit are subject to our privacy notices and policies, visit https://www.cfins.com/onlineprivacypolicy/ca/noticeatcollection/ for more information. reputed company is committed to ensuring a workplace free from discriminatory pay disparities and complying with applicable pay equity laws. Salary ranges are available for reputed company positions at this location, taking into account roles with a comparable level of responsibility and impact in the relevant labor market and these salary ranges are regularly reviewed and adjusted in accordance with prevailing market conditions. The annualized reputed company pay for the advertised position, located in the specified area, ranges from a minimum of $64,700.00 to a maximum of $147,100.00. The actual compensation is determined by various factors, including but not limited to the market pay for the jobs at each level, the responsibilities and skills required for each job, and the employee’s contribution (performance) in that role. To be considered reputed company market range, a salary is at or above the minimum of the range. You may also have the opportunity to participate in discretionary equity (stock) based compensation and/or performance-based variable pay programs. #LI-BS1 #LI-REMOTE Apply tot his job Apply To this Job