Clinical Consultant – Accident & Health

This is a fully remote position, open to applicants in United States.

📋 Description

• Facilitate effective risk management by reviewing and assessing new business and large claims/disclosures for renewals.

• Support underwriters in analyzing clinical and claims data while providing reports on findings, observations, and recommendations.

• Clarify complex clinical conditions to the team.

• Build and sustain relationships with clients, third-party administrators (TPAs), and vendors.

• Advise clients and TPAs on case management, alternative care options, program development, quality improvement, claims issues, and educational requirements.

• Collaborate with claim teams to create cost mitigation strategies and achieve favorable clinical and financial results.

• Assist with medical necessity evaluations and conduct claim audits.

• Execute reviews for transplant and complex/catastrophic care, focusing on treatment-plan medical necessity and experimental-treatment assessments.

• Provide consultation on high-cost claims and implement clinical risk management strategies.

• Assess the need for extra-contractual agreements or specialized resources and serve as a liaison until claims are resolved.

• Act as a risk management resource for claims and underwriting pertaining to Accident & Health claims.

• Set and adjust reserve recommendations, reviewing them on a monthly basis.

• Communicate risk factors, address complex inquiries, and propose continuous improvement recommendations.

⛳️ Requirements

• Minimum of 5 years of experience in clinical and case management.

• RN license is mandatory.

• CCM certification is preferred.

• A Bachelor's degree is preferred.

• Experience in stop loss and reinsurance is preferred.

• Exceptional written and verbal communication skills.

• Capable of multitasking and prioritizing effectively.

• Team-oriented but also able to work independently.

• Strong ability to establish and maintain professional relationships.

• Proficiency in Excel, Word, and spreadsheet analysis.

🏝️ Benefits

• Health and welfare benefits.

• Assistance with tuition and professional certification.

• 401k retirement savings plan.

• Optional participation in the Employee Stock Purchase Program.

• Paid time off.

• Paid holidays.

• Child bonding leave.

• Additional employee assistance programs.

• Performance-based incentives may be available.