Provide initial and updated individual medical risk analysis of self-funded and fully insured groups for proposed stop loss new business and renewals
Review a variety of claim reports including shock loss/High-Cost Claimant, spec/50%, trigger, individual paid claim detail, pending, denied, prescription, precertification and case management notes as well as individual medical questionnaires
Research medical conditions and treatment options using a variety of resources to predict potential future treatment plans, ongoing medical care and their probable costs by state and PPO
Analyze the claims, costs, and clinical information to identify high risk individuals and assess financial costs for the upcoming plan years care for claimants who may exceed the stop loss specific and communicate this to Underwriting and Sales
Document the medical review summary with specific analysis of the member’s clinical condition and annual claims projection with financial risk projection
Provide clinical guidance to other team members as needed
Review Restated Plan Documents for gap concerns and Amendments for stop Loss impact.

RN designation required
5 years of clinical experience preferably in acute care setting
Strong medical knowledge and Claims Experience w/ understanding of CPT (current procedural terminology)/ HCPCS and ICD10 codes (International Classification of Diseases), medical terminology, COBRA, HIPPA and Medicare
Strong understanding of operations of third-party administrators (TPAs) and managing general underwriters (MGUs)
Knowledge of Stop Loss, Carrier and Reinsurer reporting, plan language, and contractual requirements
Excellent written and verbal communication skills with an emphasis on confidentiality, tact, diplomacy, and ability to work independently yet support team members with clinical and claims guidance
Exceptional organizational, deductive reasoning and analytical skills along with ability to manage multiple tasks simultaneously.

Medical Underwriting Review Nurse

Key skills