Clinical Risk Manager

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

📋 Description

• Conduct analyses of medical and pharmacy claims, clinical records, treatment plans, and emerging therapies to pinpoint 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 facilitate stop loss underwriting and risk management decisions.

• Create clinical cost projections for high-dollar claimants and intricate cases.

• Oversee ongoing claims and detect changes in risk exposure.

• Deliver financial analyses and forecasts for underwriting, renewals, captives, and carrier decisions.

• Collaborate with brokers, carriers, TPAs, case management teams, specialty vendors, and employer groups on cost containment and risk reduction efforts.

• Analyze and suggest clinical and financial mitigation strategies.

• Work with stakeholders to implement cost-management approaches.

• Support captive risk management projects through clinical reviews and risk assessments.

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

• Act as a clinical resource during renewals, prospect evaluations, and risk management consultations.

• Collaborate with consultants, producers, underwriting partners, TPAs, brokers, carriers, and specialty vendors.

• Build strategic relationships and engage in multidisciplinary discussions.

• Maintain comprehensive documentation of clinical analyses, cost projections, and mitigation recommendations.

• Prepare reports, presentations, and executive summaries.

• Track outcomes and evaluate the effectiveness of mitigation strategies.

⛳️ Requirements

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

• At least 3 years of clinical nursing experience is required.

• A minimum of 2 years of experience in stop loss captive risk management is essential.

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

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

• A blend of clinical expertise with financial analysis, strategic problem-solving, and relationship management skills is necessary.

🏝️ Benefits

• Paid company holidays.

• Vacation days.

• Sick days.

• Personal days.

• Paid parental leave.

• Mental health services.

• Bonuses for full-time positions.

• Comprehensive benefits for full-time employees.

• Reasonable accommodations for individuals with disabilities.