Clinical Risk Consultant (RN)


: $89,330.00 - $131,710.00 /year *

Employment Type

: Full-Time


: Healthcare - Nursing

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This position is responsible for providing medical risk analysis for stop loss underwriters on potential ongoing risk for new business cases and in-force renewals.? The primary function is to evaluate large claimants and predict ongoing future claim costs relative to the stop loss individual specific level. This risk evaluation is presented to the stop loss underwriter who will use the information to determine how best to offset or mitigate the catastrophic risk, which could impact the overall marketability of the case.

Preferred skills?

Deep knowledge of stop loss product and comfort with medical terminology to identify catastrophic risk.

Strong communication, interpersonal and negotiation skills to interact with senior underwriters, nurses and market managers.

Very strong analytical, problem solving and decision making skills with attention to detail to assess future medical claim risks and costs.

Intermediate skill in Microsoft Excel, Office and strong Internet research skills with ability to simultaneously use multiple systems when reviewing a large claimant.

Effective self-management skills to prioritize daily work and meet deadlines based on the changing needs of senior underwriter/sales/Market Managers.


Bachelor?s degree in nursing with 3-5 years clinical experience is preferred.

BA/BS or equivalent with stop loss insurance, medical underwriting or claim experience considered


Provides individual medical risk analysis on large claimants for proposed stop loss new business and renewal business.

Reviews detailed large claim reports from a variety of sources including trigger reports, detailed individual claim reports, pending and denied reports, case management reports, and utilization reports

Analyzes medical procedures codes, medication J codes, and prescription drug reports to assist in predicting the future claim costs

Researches rare/complicated medical conditions/treatment options using resources including the internet, nursing, clinical resource tools by state/network.

Stays informed of current medical and drug trends and shares information with team members

Projects future costs of care for those claimants who may exceed the Stop loss individual specific level. Determines current treatment and cost of care based on the information received for review.

Presents and documents a clear medical review summary with an analysis of the current clinical conditions and a future annual claim projection to the senior underwriter who will then present a potential laser/premium load or other creative option to offset the risk if the stop loss deductible level is too low.

Utilizes resources provided to evaluate shock claims which include ICD-10 coding tool, prior medical underwriting reviews from past renewals, shock claims reports and internet research sites and websites that provide averages on claim costs.

Provides training to manual/senior underwriters when applicable.

Reviews any updated medical information that comes in after the initial review to determine if the future risk has changed. Notifies senior underwriter of any updates to the original risk projection.

Associated topics: ambulatory, asn, bsn, care, maternal, neonatal, nurse clinical, psychatric, psychiatric, unit * The salary listed in the header is an estimate based on salary data for similar jobs in the same area. Salary or compensation data found in the job description is accurate.

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