Clinical Risk Manager

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

📋 Description

• Conduct analysis of medical and pharmacy claims, clinical records, treatment plans, and new therapies to detect high-cost claim exposure and stop loss risk.

• Assess current and future claim liabilities related to oncology, transplants, specialty pharmacy, gene and cell therapy, catastrophic claims, and chronic conditions.

• Evaluate clinical severity, treatment trends, and emerging risks to inform stop loss underwriting and risk management strategies.

• Create clinical cost forecasts for high-dollar claimants and complex cases.

• Track significant ongoing claims and shifts in risk exposure.

• Deliver financial analyses and projections for underwriting, renewals, captive, and carrier decisions.

• Collaborate with brokers, carriers, TPAs, case management teams, specialty vendors, and employer groups to enhance cost containment and mitigate risk.

• Assess and propose clinical and financial solutions for risk mitigation.

• Work with stakeholders to execute cost-management initiatives.

• Support captive risk management efforts through clinical evaluations and risk assessments.

• Communicate complex clinical data to clients, brokers, captives, carrier partners, and executive leadership.

• Act as a clinical resource during renewals, prospect assessments, and risk management discussions.

• Cultivate strategic relationships and engage in multidisciplinary dialogues.

• Maintain records of clinical assessments, cost projections, and mitigation suggestions.

• Prepare reports, presentations, and executive summaries.

• Evaluate the results and effectiveness of mitigation strategies.

⛳️ Requirements

• Associate's or Bachelor's Degree in Nursing or a related healthcare discipline is preferred.

• A minimum of 3 years of clinical nursing experience is required.

• At least 2 years of experience in stop loss captive risk management is necessary.

• Experience in evaluating complex and catastrophic claims is highly preferred.

• An active and unrestricted Registered Nurse (RN) license is required.

• A combination of clinical expertise with financial analysis, strategic problem-solving, and collaborative relationship management is essential.

🏝️ Benefits

• Paid company holidays.

• Vacation days.

• Sick days.

• Personal days.

• Paid parental leave.

• Mental health services.

• Bonuses for full-time positions.

• Comprehensive benefits package.

• Reasonable accommodations for individuals with disabilities.