Captive Resources, LLC · 2 weeks ago
Clinical Risk Manager RN
Itasca, Illinois, United States
Full-time
Onsite
Entry, Mid Level
2+ years expCaptive Resources, LLC is focused on health solutions and medical stop loss, and they are seeking a Clinical Risk Manager RN. The role involves providing case management and claims management consulting to assess high-cost cases and support underwriting processes.
Insurance
Responsibilities
Reviewing stop-loss cases, making recommendations on potential cost of care, including lasers recommendations
Use established guidelines when conducting stop-loss case reviews
Works with underwriting team to identify potential high-risk claimants in new business and renewal groups
Elicits support from sales and account management, and underwriting
Use reporting and risk identification tools on medical and pharmacy claims to assess risk
Assists in responding to inquiries from underwriting and sales for additional information on large claimants
Review of monthly TPA reporting on current business for reserving
Understanding of health and prescription costs
Understanding of health delivery systems and professionals
Understanding of disease life cycle, disease progression, expected health outcomes based on standard, accepted care management principles
Understanding of stop loss reporting tools and requirements preferred
Understanding of risk mitigation, high claimant detection, engagement and management preferred
Requires strong interpersonal skills with a demonstrated ability to work across divisions and with external stakeholders
Requires proficiency in the use of MS Office, AMS product suite, and ESL Office
Qualification
Required
ASN or BSN in nursing licensed in the State of Residence
At least two (2) years of clinical experience
At least two (2) years of stop loss or health payer experience
Reviewing stop-loss cases, making recommendations on potential cost of care, including lasers recommendations
Use established guidelines when conducting stop-loss case reviews
Works with underwriting team to identify potential high-risk claimants in new business and renewal groups
Elicits support from sales and account management, and underwriting
Use reporting and risk identification tools on medical and pharmacy claims to assess risk
Assists in responding to inquiries from underwriting and sales for additional information on large claimants
Review of monthly TPA reporting on current business for reserving
Understanding of health and prescription costs
Understanding of health delivery systems and professionals
Understanding of disease life cycle, disease progression, expected health outcomes based on standard, accepted care management principles
Requires strong interpersonal skills with a demonstrated ability to work across divisions and with external stakeholders
Requires proficiency in the use of MS Office, AMS product suite, and ESL Office
Preferred
Understanding of stop loss reporting tools and requirements
Understanding of risk mitigation, high claimant detection, engagement and management
Company
Captive Resources, LLC
For four decades, Captive Resources has provided mid-market companies the ability to become insurance company owners rather than insurance buyers and to lower their total cost of risk.
201-500 employees
Funding
Current Stage
Growth StageTotal Funding
unknown2012-01-01Private Equity
Leadership Team
Nick J. Hentges
Chief Executive Officer
Recent News
2024-05-21
Company data provided by crunchbase