Summary of Job
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. Review detailed large claim reports and available clinical information from a variety of sources including trigger reports, detailed individual claim reports, pending and denied reports, case management reports, and utilization reports. Present and document a clear medical review summary with an analysis of the current clinical conditions and a future annual claim projection to underwriting team.
Responsibilities
• Research rare/complicated medical conditions/treatment options using resources including the internet, nursing, clinical resource tools by state/network.
• Ensure timely and accurate communications of medical necessity review results to the original requester (e.g., primary care team, specialty providers, vendors) in compliance with regulatory and contractual requirements.
• Analyze medical procedures codes, medication J codes, and prescription drug reports to assist in predicting the future claim costs and clinical prognosis utilization needs.
• Make recommendations based on medical review summary; conduct necessary referrals to Clinical Cost Containment Services; partner with team(s) as needed to ensure care plan and approach are effective to support financial risk 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 requested or deemed appropriate.
• Consult with internal and external clients on high cost claims and successfully engage effective clinical risk management strategies.
• Plan and develop work plans, establish timelines, and set goals for assigned work.
• Utilize a comprehensive approach to risk mitigation within area of responsibility by monitoring regulatory changes to ensure on-going adherence to reporting requirements.
• Stay informed of current medical and drug trends and share information with team members.
Qualifications
• Registered Nurse (RN) (Required)
• Bachelor’s Degree in Nursing or related clinical field (Preferred)
• 4 – 6+ years of professional relevant work experience (Required)
• 4 years’ experience in medical underwriting or medical risk management, clinical coding or AHIP certification (Required)
• Three years’ direct clinical experience, preferably in an acute care (Required)
• Additional years of experience/specialized training may be considered in lieu of educational requirements (Required)
• Ability to successfully work independently; organizational skills; ability to manage multiple tasks simultaneously (Required)
• Demonstrated analytical skills; ability to exercise sound judgment, initiative and discretion (Required)
• Proficient with MS Office - Word, Excel, PowerPoint, Outlook (Required)
• Demonstrated ability to establish effective working relationships with coworkers and customers (Required)
• Knowledge of ICD 10 coding and medical terminology (Required)
• Knowledge of state and federal regulations related to underwriting (Required)
• Strong verbal, written, interpersonal communication and customer service skills (Required)
• Ability to interpret policies and procedures and communicate complex clinical topics effectively (Required)