![Company logo](https://coda.newjobs.com/api/imagesproxy/ms/clu/xjob/xjobot2018x/branding/161229/jobot-logo-638532683514160433.png)
Stop Loss Nurse Reviewer at Jobot
New York, NY 10001
About the Job
FULLY REMOTE
This Jobot Job is hosted by: Ryan Esposito
Are you a fit? Easy Apply now by clicking the "Quick Apply" button
and sending us your resume.
Salary: $80,000 - $120,000 per year
A bit about us:
premier national leading resource for a comprehensive suite of high quality care management services including Utilization Management, Case Management, Physician Review, and Nurse Helpline/Health Information. The company also offers other vital services ranging from Disease Management, Disability Management, Readmission Management, and Maternity Management, Medical Claims Review and Network Referrals.
Why join us?
We consider our employees our greatest asset. We provide a positive work environment that rewards professionalism, hard work and a commitment to the highest standards of customer service. Each employee is given the opportunity to develop their skills, advance and achieve personal fulfillment. A competitive compensation package, coupled with a congenial work atmosphere, has made Amalgamated Medical Care Management an organization with many longstanding, loyal employees.
Job Details
This position is responsible for reviewing stop loss risk cases, determining potential cost of care, making recommendations on lasers and other stop-loss related activities. Works closely with our affiliate company's underwriting team. This position reports to the Supervisor, Stop-loss Review Nurse and to the Director of Utilization and Case Management.
Essential Duties and Responsibilities:
· This position is responsible for reviewing stop-loss cases, making recommendations on potential cost of care, including lasers.
· Uses established guidelines when conducting stop-loss case reviews.
· Works with the underwriting team to identify potential high risk patients in new business and renewal groups, and to assess patient's clinical need against established guidelines, ensuring care levels are medically necessary and appropriate.
· When appropriate, works with the CM team to ensure potential high risk claimants are engaged in care management protocols.
· Elicits support from sales and account management, brokers, consultants and group customers.
· Uses reporting and risk identification tools on medical and pharmacy claims to assess risk.
· Assists underwriting in evaluating risks in existing and potential stop loss groups.
· Assists in responding to inquiries from our affiliate company, sales and other partners for additional information on large claimants.
· Acts as a resource to sales and account management teams in communicating with stop-loss management.
· Performs other duties as may be assigned by management
Education and/or Experience:
· Requires an ASN or BSN in nursing licensed in the state of residence.
· Requires a minimum of two (2) years of clinical experience.
· Requires minimum of two (2) years of experience in the stop-loss industry, the health care delivery system/industry or health care payer experience.
Knowledge and skills:
· Requires understanding of health and prescription costs.
· Requires understanding of health delivery systems and professionals.
· Requires 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 inter-personal skills with a demonstrated ability to work across divisions and with external stakeholders.
· Requires proficiency in the use of personal computers and in supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint, MS Project).
Physical Demands:
· Ability to work in a limited space.
· Lifting up to 25 lbs. on occasion.
· Ability to work from home in a HIPAA compliance home office environment.
Schedule:
Education:
Experience:
License/Certification:
Work Location: Remote
Interested in hearing more? Easy Apply now by clicking the "Quick Apply" button.
This Jobot Job is hosted by: Ryan Esposito
Are you a fit? Easy Apply now by clicking the "Quick Apply" button
and sending us your resume.
Salary: $80,000 - $120,000 per year
A bit about us:
premier national leading resource for a comprehensive suite of high quality care management services including Utilization Management, Case Management, Physician Review, and Nurse Helpline/Health Information. The company also offers other vital services ranging from Disease Management, Disability Management, Readmission Management, and Maternity Management, Medical Claims Review and Network Referrals.
Why join us?
We consider our employees our greatest asset. We provide a positive work environment that rewards professionalism, hard work and a commitment to the highest standards of customer service. Each employee is given the opportunity to develop their skills, advance and achieve personal fulfillment. A competitive compensation package, coupled with a congenial work atmosphere, has made Amalgamated Medical Care Management an organization with many longstanding, loyal employees.
Job Details
This position is responsible for reviewing stop loss risk cases, determining potential cost of care, making recommendations on lasers and other stop-loss related activities. Works closely with our affiliate company's underwriting team. This position reports to the Supervisor, Stop-loss Review Nurse and to the Director of Utilization and Case Management.
Essential Duties and Responsibilities:
· This position is responsible for reviewing stop-loss cases, making recommendations on potential cost of care, including lasers.
· Uses established guidelines when conducting stop-loss case reviews.
· Works with the underwriting team to identify potential high risk patients in new business and renewal groups, and to assess patient's clinical need against established guidelines, ensuring care levels are medically necessary and appropriate.
· When appropriate, works with the CM team to ensure potential high risk claimants are engaged in care management protocols.
· Elicits support from sales and account management, brokers, consultants and group customers.
· Uses reporting and risk identification tools on medical and pharmacy claims to assess risk.
· Assists underwriting in evaluating risks in existing and potential stop loss groups.
· Assists in responding to inquiries from our affiliate company, sales and other partners for additional information on large claimants.
· Acts as a resource to sales and account management teams in communicating with stop-loss management.
· Performs other duties as may be assigned by management
Education and/or Experience:
· Requires an ASN or BSN in nursing licensed in the state of residence.
· Requires a minimum of two (2) years of clinical experience.
· Requires minimum of two (2) years of experience in the stop-loss industry, the health care delivery system/industry or health care payer experience.
Knowledge and skills:
· Requires understanding of health and prescription costs.
· Requires understanding of health delivery systems and professionals.
· Requires 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 inter-personal skills with a demonstrated ability to work across divisions and with external stakeholders.
· Requires proficiency in the use of personal computers and in supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint, MS Project).
Physical Demands:
· Ability to work in a limited space.
· Lifting up to 25 lbs. on occasion.
· Ability to work from home in a HIPAA compliance home office environment.
Schedule:
- Day shift
Education:
- Associate (Required)
Experience:
- Registered Nurse: 3 years (Required)
- Claims review or stop loss, high risk claimants: 2 years (Required)
License/Certification:
- RN License (Required)
Work Location: Remote
Interested in hearing more? Easy Apply now by clicking the "Quick Apply" button.
Salary
80,000 - 120,000 /year