临床顾问 事故与健康
Clinical Consultant, Accident & Health
主管职责和责任
- 确保有效的风险管理。进行审查、新业务评估和大额索赔/披露的评估，以识别已知和潜在风险。
- 协助精算师对临床和索赔数据进行评估和分析，通过提供简洁、详细且准确的数据分析结果、观察结果和建议，来识别和量化已知和潜在风险。
- 向团队有效解释复杂的临床状况。
- 发展并维护与客户、TPA和供应商的良好关系。
- 与客户和TPA就个案管理问题、替代护理级别、项目开发、质量改进、索赔问题和教育需求进行咨询。
- 与索赔团队合作，确定影响，制定成本缓解策略，并与内部和外部利益相关者合作，以实现有效的临床和财务结果。
- 协助进行医疗必要性判断和索赔审计。
- 按需执行：移植和其他复杂/灾难性护理的审查，包括对治疗方案的医疗必要性/实验性治疗、护理设置的适当性以及与外部医学专家协调的任何必要额外审查的评估。
- 就高成本索赔与内部和外部客户进行咨询，并成功实施有效的临床风险管理策略。
- 确定是否需要额外的合同协议和/或专业资源的参与，并作为联络人直至索赔完成。
- 作为与A&H索赔的风险管理相关的索赔和精算方面的资源。
- 建立准备金建议，并根据需要进行调整，每月进行审核。
- 与内部和外部客户建立牢固的关系，传达风险因素，解决复杂问题，并为持续改进制定建议。
资格、教育和经验要求
- 5年以上临床和个案管理经验
- 需要注册护士执照
- 优先考虑CCM认证
- 优先考虑学士学位
- 优先考虑止损和再保险经验
- 优秀的书面和口头沟通能力
- 能够多任务处理和优先排序
- 以团队为导向，同时能够独立工作
- 能够建立和维护良好的专业关系
- 熟练使用Excel、Word和电子表格分析
薪酬与福利
适用的基本薪资
查看英文原文
Principal Duties and Responsibilities
- Ensure effective risk management. Perform reviews, assessment of new business, and renewal large claims/disclosure to identify known and potential risk.
- Assist underwriters in the evaluation and assessment of clinical and claims data to identify and quantify known and potential risk through the provision of concise, detailed, and accurate reporting of data analysis findings, observations and recommendations to underwriting.
- Effectively explain complex clinical conditions to team.
- Develop and maintain strong client, TPA and vendor relationships.
- Consult with clients and TPA’s on case management issues, alternative levels of care, program development, quality improvement, claims issues and educational needs.
- Work with claim team to determine the need to impact, develop a cost mitigation strategy and work with internal as well as external stakeholders to produce an effective clinical and financial outcome.
- Assist with medical necessity determinations and claim audits.
- Perform as needed: transplant and other complex /catastrophic care reviews including review of treatment plan for medical necessity/experimental treatment, appropriateness of setting and coordination of any necessary additional review with outside medical expert.
- Consult with internal and external clients on high cost claims and successfully engaged effective clinical risk management strategies.
- Determine need for extra contractual agreements and /or engagement of specialty resources and acts as a liaison until the claim is complete.
- Serve as a resource for claims and underwriting related to the risk management of A&H claims.
- Establish reserve recommendations and adjusted as needed and reviewed on a monthly basis.
- Build strong relationships with internal and external clients and communicated risk factors, resolved complex inquires and developed recommendations for continuous improvement.
Qualifications, Education and Experience Preferred
- 5+ years of clinical and case management experience
- RN license required
- CCM preferred
- Bachelor's degree preferred
- Stop loss and reinsurance experience preferred
- Excellent written and oral communication skills
- Ability to multi-task and prioritize
- Team oriented yet able to work independently
- Ability to build and maintain strong professional relationships
- Proficiency with Excel, Word and spreadsheet analysis
Compensation & Benefits
The applicable base salary for this opportunity is $80,000 - $130000. The base pay offered will be determined by factors such as experience, skills, training, location, certifications, education, and any applicable minimum wage requirements. In addition to the base salary, this opportunity may be eligible for performance-based incentives. We are excited to offer a competitive total rewards package which includes health and welfare benefits, tuition and professional certification assistance, 401k savings, elective participation in the Employee Stock Purchase Program, paid time off, paid holidays, and child bonding leave, as well as other employee assistance.
Originally posted on Himalayas