Job description
Summary of Position
Assess medical risk for each identified claimant utilizing all available information and applying appropriate guidelines to meet
the financial risk management goals of the company.
the financial risk management goals of the company.
- Review detailed large claim reports and available clinical information from a variety of sources including trigger reports,
- Present and document a clear medical review summary with an analysis of the current clinical conditions and a future annual
Principal Accountabilities
- Research rare/complicated medical conditions/treatment options using resources including the internet, nursing,
- Ensure timely and accurate communications of medical necessity review results to the original requester (e.g., primary
- Analyze medical procedures codes, medication J codes, and prescription drug reports to assist in predicting the future
- Make recommendations based on medical review summary; conduct necessary referrals to Clinical Cost Containment
management and clinical cost containment based on the identified clinical needs and predicted prognosis.
- Provide clinical opinion from knowledge, experience and/or research to claims examiners and underwriters as
- Consult with internal and external clients on high cost claims and successfully engage effective clinical risk
- Plan and develop work plans, establish timelines, and set goals for assigned work. 15%
- Utilize a comprehensive approach to risk mitigation within area of responsibility by monitoring regulatory changes to
- Stay informed of current medical and drug trends and share information with team members.
Education, Training, Licenses, Certifications
- Registered Nurse (RN) (R)
- Bachelor’s Degree in Nursing or related clinical field (P)
Relevant Work Experience, Knowledge, Skills, and Abilities
- 4 – 6+ years of professional relevant work experience. (R)
- 4 years’ experience in medical underwriting or medical risk management, clinical coding or AHIP certification. (R)
- Three years’ direct clinical experience, preferably in an acute care. (R)
- Additional years of experience/specialized training may be considered in lieu of educational requirements. (R)
- Ability to successfully work independently; organizational skills; ability to manage multiple tasks simultaneously. (R)
- Demonstrated analytical skills; ability to exercise sound judgment, initiative and discretion. (R)
- Proficient with MS Office (Word, Excel, Powerpoint, Outlook). (R)
- Demonstrated ability to establish effective working relationships with coworkers and customers. (R)
- Knowledge of ICD 10 coding and medical terminology. (R)
- Knowledge of state and federal regulations related to underwriting. (R)
- Strong verbal, written, interpersonal communication and customer service skills. (R)
- Ability to interpret policies and procedures and communicate complex clinical topics effectively. (R)
Additional Information
- Job Type: Standard
- Schedule: Full-time
- Employee Status: Regular
- Requisition ID: 1000000524
- Hiring Range: $75,000-$95,000
johnandkristie.com is the go-to platform for job seekers looking for the best job postings from around the web. With a focus on quality, the platform guarantees that all job postings are from reliable sources and are up-to-date. It also offers a variety of tools to help users find the perfect job for them, such as searching by location and filtering by industry. Furthermore, johnandkristie.com provides helpful resources like resume tips and career advice to give job seekers an edge in their search. With its commitment to quality and user-friendliness, johnandkristie.com is the ideal place to find your next job.