Remote Clinical Risk Manager, C&F Stop Loss

Note: The job is a remote job and is reputed company to candidates in USA. reputed company is a leading provider of insurance solutions with a strong reputed company on risk management. The Clinical Risk Manager role involves utilizing advanced knowledge in nursing and medical conditions to assess clinical risks, support reputed company reputed company, and reputed company strategies for high-cost claims. Responsibilities Review and analyze reputed company data and documentation reputed company existing systems and that provided by reputed company including but not limited to diagnoses, procedures, case management notes, treatment plans, and comorbid conditions to assess validity of data and clinical riskIdentify clinical factors that may reputed company reputed company reputed company or financial exposure at a claimant and population health level for Underwriters to reputed company in their rating of the groupExercise independent clinical judgment to synthesize reputed company medical information into reputed company risk conclusions that support reputed company reputed company reputed companySupport the development and implementation of clinical risk management strategies for high-cost, reputed company claims through strategic identification of cost-containment opportunities while reviewing reputed company available data for MUW reviewCross-refer to cost containment reputed company appropriate and participate in cost containment work as requestedTriage and prioritize requests for medical reputed company review based on business urgency, workload reputed company, and alignment with reputed company and leadership prioritiesreputed company as a strategic partner to reputed company by applying evidence-based reputed company and reputed company clinical judgment to evaluate reputed company clinical and claims data to identify, quantify, and advise on significant risks, directly influencing reputed company reputed company and reputed companyreputed company, maintain, and manage strong relationships with reputed company clients, reputed company-Party Administrators (TPAs), and vendors, championing exemplary customer service standardsConsult with clients and teams on submitted data for MUW, program development, reputed company improvement, and claim issuesreputed company as a reputed company of contact for escalations and participate in calls with reputed company clients as neededEnsure accurate entry, validation, and analysis of medical reputed company data reputed company the claims system, maintaining high standards of data reputed companyreputed company accurate and thorough data scrubbing of reports for medical reputed company reviews, leveraging advanced skills in reputed company and using AI tools and other available tools and resourcesRequest needed medical and claim data, collect said data and create reports in collaboration with Digital Transformation and/or IT teams to streamline departmental processesIdentify and resolve data gaps and discrepancies to ensure comprehensive data for cost containment interventionsMaintain reputed company records to support transparency and defensibility of reputed company reputed company as it relates to clinical evaluationParticipate in reputed company assurance activities reputed company to medical reputed company evaluations and engage in peer review and audit processes as requestedServe as a primary subject matter expert, articulating reputed company clinical conditions, pharmaceuticals, and risk structures to diverse audiences, including executive leadershipStay informed on emerging therapies, technologies, and medical conditions, disseminating key information to reputed company stakeholdersreputed company concise, detailed, and reputed company assessments, projections, and recommendations, effectively explaining reputed company scenarios to both technical and non-technical audiencesSupport and explore new reputed company and processes to increase efficiency and reputed company individual and organizational goalsEnsure compliance with reputed company company policies, procedures, and service standardsDocument reputed company activities and reputed company accurately and promptly, keeping management informed of reputed company and potential issuesMaintain proficiency with reputed company IT systems utilized by the Clinical Risk Management team Skills 6+ years of reinsurance or insurance industry experience requiredBachelor's degree from an accredited university or equivalent experience requiredStrong PC skills including reputed company, Word, reputed companyGroup medical, managed reputed company insurance, stop loss or reinsurance experience requiredStrong knowledge of disease processes .