RN, Data Analyst

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Concentrate on stop loss risk management efforts within the centralized stop loss team and collaborate on risk oversight with care delivery areas.

• Ensure that care is synchronized across the organization and throughout the care delivery system for high-risk members.

• Apply established guidelines to guarantee appropriate care levels and facilitate transitions of care.

• Collaborate with care management and delivery operations to identify potential high-risk patients in new business and renewal groups.

• Evaluate patients' clinical needs according to established guidelines.

• Confirm that high-risk claimants are involved in care management protocols.

• Gather support from sales, account management, brokers, consultants, and group customers.

• Coordinate assistance for high-risk patients with their families, employers, and other relevant parties.

• Utilize reporting and risk identification tools related to medical and pharmacy claims to evaluate risk.

• Maintain care management protocols for members receiving care outside the designated service area.

• Aid in assessing risks in existing and potential stop loss groups.

• Collaborate with pharmacy management regarding specialty drug usage and service delivery locations.

• Assess care, analyze variances, and engage in quality improvement initiatives.

• Address inquiries from preferred partners concerning large claimants.

• Serve as a resource for sales and account management teams regarding case management services and stop loss management.

• Identify and oversee high-risk claimants within established and prospective stop loss customers.

• Ensure suitable care levels and engagement across company functions and care delivery systems.

• Execute other responsibilities as assigned by management.

⛳️ Requirements

• Minimum of a high school diploma or GED.

• Preferably an Associate's or Bachelor's degree (or higher) in nursing and/or a health-related field OR a diploma from an accredited nursing school.

• Requires at least two (2) years of clinical experience.

• Requires a minimum of three (3) years of experience in the health care delivery system/industry.

• Requires at least two (2) years of experience with health care payer operations.

• Requires a valid NJ Registered Nurse License.

• Prefers pending or obtained certification in case management or other relevant clinical specialties.

• Prefer advanced skills in Excel, SQL, or Tableau.

• Experience in creating dashboards and reports is necessary.

• Requires a solid understanding of health and prescription insurance products, contracts, and benefits eligibility.

• Requires knowledge of health delivery systems and professionals.

• Requires familiarity with case/care/disease management principles.

• Requires strong interpersonal skills with a proven ability to collaborate across divisions and with external stakeholders.

• Requires proficiency in using personal computers and supporting software in a Windows environment, including MS Office products (Word, Excel, PowerPoint, MS Project) and Lotus Notes.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision).

• Retirement Plans.

• Generous PTO.

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.