Clinical Risk Manager- Remote - Crum & Forster

Since 2000, Crum & Forster’s Accident & Health division (A&H) has offered a diverse portfolio of specialty insurance and reinsurance products nationwide. We place a strong focus on product development and creative distribution methods, along with excellent client service and support.

In addition to our robust domestic portfolio, which spans both special risk and medical solutions, A&H works on an international basis through various partnerships. Our global capabilities provide our partners with even broader flexibility in underwriting solutions.

The qualities and capabilities of Crum & Forster Accident & Health demonstrate our philosophy of building meaningful, long-term partnerships and our dedication to providing alternative strategies in an ever-changing insurance market.

The A&H MBU takes a full-spectrum approach to designing and servicing a robust slate of products tailored to needs in Employer Stop Loss, Excess Medical, Life, and Ancillary and Supplemental benefits. Our diversified business model includes program partnerships as well as direct sales in Employer Stop Loss. At year-end 2023, the MBU recorded $741M in gross premium written.

Information about the Role, Line of Business and Team:

The Clinical Risk Manager role utilizes a high level of experience and advanced knowledge regarding medical conditions, risk and prognoses as it relates to treatment plans and utilization of care in order to provide accurate projected risk (laser) or procedure related lasers for upcoming plan year. This individual will also be responsible for executing cost containment services for assigned groups.

What you will do:

• Ensure effective risk management. Consult with internal and external clients on high cost claims and successfully engage in effective clinical risk management strategies
• Determine need for extra contractual agreements &/or engagement of specialty resources and acts as a liaison until claim is complete
• Establish reserve recommendations
• Assist with medical necessity determinations and claim audits
• Assist underwriters in the evaluation and assessment of clinical and claims data to identify and quantify known and potential risk
• Provide accurate and thorough data scrubbing of reporting provided for risk assessments
• Provide concise, detailed and accurate reporting of data analysis findings, observations and recommendations to underwriting
• Effectively explain complex clinical conditions to a lay person
• Develop and maintain strong client, TPA and vendor relationships
• Consult with clients and TPAs on case management issues, alternative levels of care, program development, quality improvement, claim issues and educational needs
• Participate in TPA implementation calls
• Facilitate timely and accurate intake, triaging, tracking and documentation of potential/actual claims. Quickly, thoroughly and correctly assess a potential/actual claim situation, determine need to impact, develop a sound strategy and successfully influence stakeholders to produce a meaningful clinical &/or financial outcome
• Accurately analyze transplant contracts, recommend best option, facilitate execution of third party transplant center of excellent access agreement and assure timely referral. Document activity and outcomes accurately and promptly
• Assist with developing specialty networks to assist TPAs/MGUs with cost containment options/availability for claims cost containment
• Help develop and drive medical cost containment program
• Other special projects and duties as required

What YOU will bring to C&F:

• Ability to read and research medical history reports while utilizing multiple resources and applying judgement in determining the final decision with appropriate supportive documentation
• Ability to examine and interpret reports (i.e. trigger reports, pended claims reports, pre-cert reports, case management reports, RX reports, etc.) to determine degree of risk
• Demonstrated success in a service/consultative role
• A high level of service delivery in efforts to do what is necessary to ensure customer satisfaction
• Ability to establish a good rapport with all customers and internal team members/staff
• Ability to analyze relevant aspects of a situation before reaching a conclusion, with no hesitation to take action when required
• A focus on accuracy when completing all projects
• A sustained effort and dedication to getting the job done well, while working continuously to produce superior work regardless of obstacles or setbacks
• Demonstrate a solid work ethic and maintain a positive attitude
• Displays personal concern, interest, pride and accountability in all areas of responsibility
• Ability to work both independently and in a team environment
• Expert with negotiating, persuasion and conflict resolution skills
• Strong organization and time management skills with exceptional attention to detail
• Ability to clearly present information through the spoken or written word, as well as read and interpret complex information with moderate supervision
• Ability to effectively handle multiple tasks in a fast-paced environment

• A quick learner with the willingness and ability to acquire new skills

Requirements:

• Bachelor’s degree from an accredited university or equivalent experience required
• 5-10 years clinical experience with a current unrestricted licensure as a health professional (Registered Nurse), as well as 5+ years of case/claim management experience
• Strong PC skills including Excel, Word, Outlook
• Proficiency in Stop Loss Office/David Young ESL system
• Group medical, managed care, health insurance, stop loss or reinsurance experience
• Strong knowledge of disease processes and treatment plans

• Competitive compensation package
• Generous 401K employer match
• Employee Stock Purchase plan with employer matching
• Generous Paid Time Off
• Excellent benefits that go beyond health, dental & vision. Our programs are focused on your whole family’s wellness, including your physical, mental and financial wellbeing
• A core C&F tenet is owning your career development, so we provide a wealth of ways for you to keep learning, including tuition reimbursement, industry-related certifications and professional training to keep you progressing on your chosen path
• A dynamic, ambitious, fun and exciting work environment
• We believe you do well by doing good and want to encourage a spirit of social and community responsibility, matching donation program, volunteer opportunities, and an employee-driven corporate giving program that lets you participate and support your community
  

At C&F you will BELONG

We value inclusivity and diversity. We are committed to equal employment opportunity and welcome everyone regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. If you require special accommodation, please let us know.

For California Residents Only:  Information collected and processed as part of your career profile and any job applications you choose to submit are subject to our privacy notices and policies, visit https://www.cfins.com/onlineprivacypolicy/ca/noticeatcollection/ for more information.

Crum & Forster is committed to ensuring a workplace free from discriminatory pay disparities and complying with applicable pay equity laws.  Salary ranges are available for all positions at this location, taking into account roles with a comparable level of responsibility and impact in the relevant labor market and these salary ranges are regularly reviewed and adjusted in accordance with prevailing market conditions. The annualized base pay for the advertised position, located in the specified area, ranges from a minimum of $64,700.00 to a maximum of $147,100.00. The actual compensation is determined by various factors, including but not limited to the market pay for the jobs at each level, the responsibilities and skills required for each job, and the employee’s contribution (performance) in that role. To be considered within market range, a salary is at or above the minimum of the range. You may also have the opportunity to participate in discretionary equity (stock) based compensation and/or performance-based variable pay programs.

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