Medical Risk Consultant, RN

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

📋 Description

• Analyze stop-loss claim notifications and claimant medical documentation to pinpoint high-cost trajectories prior to incurring excess loss.

• Create comprehensive clinical evaluations that convert prognosis and treatment paths into practical underwriting recommendations.

• Actively engage with stop-loss carrier partners to negotiate the reduction or elimination of lasers during renewal processes.

• Provide clinical education to internal teams, TPA partners, and the adviser network regarding high-cost diagnoses.

⛳️ Requirements

• Over 5 years of direct clinical nursing experience in an acute care environment, such as ICU, oncology, transplant, surgical, or complex chronic disease management.

• A valid, unencumbered RN license; preference for a compact state license due to the remote and multi-state nature of the role.

• Minimum of 3 years of experience in case management, utilization review, or payer-side roles within a TPA, HMO, PPO, stop-loss carrier, or reinsurance company.

• Familiarity with the operations of stop-loss insurance, self-funded health plans, and TPA functions.

• Certification as a Certified Case Manager (CCM).

🏝️ Benefits

• Performance bonus: up to 10% of base salary linked to quantifiable cost containment results (MBO).

• Health and dental insurance coverage.

• Life insurance, as well as short-term and long-term disability insurance.

• 401(k) retirement plan.

• Paid time off (PTO).

• Travel opportunities: Up to 10% for consortium events, visits to TPA partners, and participation in industry conferences.