Excess Risk Managed Care Clinician

Job ID: J135039
Company: HM Life Insurance Company
Location: Home, IL, United States
Facility: Work From Home
Full/Part Time: Full time
Job Type: Regular
Posted at: Nov 7, 2018

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Description

I.    GENERAL OVERVIEW:  
Acting in the role of Excess Risk Managed Care Clinician, this position is responsible for analyzing clinical data to assess potential stop loss claim liability, utilizing Case Management oversight techniques to ensure front line case management and cost containment activities are occurring at the first dollar level. This role provides pre-sale and renewal support to underwriting in evaluating potential claims that impact the risk, communicates effectively with Third Party Administrators, CM/UM vendors, department staff and all levels of department management and coaches, consults and mentors team members on moderate to complex clinical issues.

Employee Referral Payout: Level 1

**This is a Work From Home Position traveling nationally 20% of the time.


II.    ESSENTIAL RESPONSIBILITIES:  
1.    Analyzing clinical data to assess potential stop loss claim liability and utilizing Case Management oversight techniques to ensure front line case management and cost containment activities are occurring at the first dollar level.

  • Review all triaged notices of potential claims and make assessments regarding potential claims.
  • Communicate with TPA Case Managers and/or their contracted CM/UM vendors to ensure effective case/care management, of all potential and actual stop loss claims with the overall objective of cost management. 
  • Verify network status and work with TPA Case Managers and/or internal cost containment staff to obtain discounting on all out of network claims and to review/reduce all claims that include excessive charges.
  • Document findings according to department guidelines for documentation.

2.    Providing pre-sale and renewal support to underwriting in evaluating potential claims that impact the risk.

  • Evaluate potential high dollar claims as it relates to risk assessment using a variety of research sources as well as experiential knowledge to project future costs based on diagnosis, age and co-morbidities.

3.    Communicating effectively with Third Party Administrators, CM/UM vendors, department staff and all levels of department management.

  • Build and relationships with TPA Case Managers and CM/UM vendors to ensure the exchange of clinical information between HMIG and the other party is occurring.
  • Identify and articulate problems and/or issues to various staff members including all levels of department management.
  • Participate in functional walk-throughs.

4.    Coaching, consulting and mentoring team members on moderate to complex clinical issues.  Provide ad-hoc job training to include:

  • Moderate to complex business/system functionality 
  • Review of desktop  procedures  and training material
  • Provide feedback on team members’ performance
  • Provide subject matter expertise for new trainees

5.    Promoting a culture of performance excellence.

  • Enhancing skills through the quality improvement process.
  • Participating in process and operational improvement initiatives
  • Building and maintaining effective relationships throughout the department to advance performance excellence.

6.    Other duties as assigned or requested.

III. QUALIFICATIONS:
Minimum

  • Current RN license
  • Minimum of 2 years experience in case management in a clinical and/or business setting

Preferred

  • Bachelor’s Degree in nursing
  • Demonstrated working knowledge of the excess risk product and related claim management/cost containment techniques.
  • Strong understanding of self-funding, Third Party Administration and Managed Care.
  • Prior experience in the insurance industry with claim management.


Knowledge, Skills and Abilities  (This section describes additional preferred characteristics)

  • Strong organizational skills

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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