Nurse Clinician
2 weeks ago
We are seeking an experienced Nurse Clinician - Risk Mitigation to join our underwriting team at Emblem Health. This role involves assessing medical risk, analyzing data, and making recommendations to support financial risk management goals.
Key Responsibilities:
- Assess medical risk for each identified claimant utilizing all available information and applying appropriate guidelines to meet the financial risk management goals of the company.
- Review detailed large claim reports and available clinical information from various sources, including trigger reports, detailed individual claim reports, pending and denied reports, case management reports, and utilization reports.
- Present and document a clear medical review summary with an analysis of the current clinical conditions and a future annual claim projection to the underwriting team.
- Analyze medical procedures codes, medication J codes, and prescription drug reports to assist in predicting future claim costs and clinical prognosis utilization needs.
- Make recommendations based on medical review summaries and conduct necessary referrals to Clinical Cost Containment Services as needed.
- Provide clinical opinions from knowledge, experience, and/or research to claims examiners and underwriters as requested or deemed appropriate.
Requirements:
- Registered Nurse (RN) (Required)
- Bachelor's Degree in Nursing or related clinical field (Preferred)
- 4-6+ years of professional relevant work experience (Required)
- 4 years' experience in medical underwriting or medical risk management, clinical coding, or AHIP certification (Required)
- Three years' direct clinical experience, preferably in an acute care setting (Required)
- Additional years of experience/specialized training may be considered in lieu of educational requirements (Required)
- Ability to successfully work independently; organizational skills; ability to manage multiple tasks simultaneously (Required)
- Demonstrated analytical skills; ability to exercise sound judgment, initiative, and discretion (Required)
- Proficient with MS Office - Word, Excel, PowerPoint, Outlook (Required)
- Demonstrated ability to establish effective working relationships with coworkers and customers (Required)
- Knowledge of ICD 10 coding and medical terminology (Required)
- Knowledge of state and federal regulations related to underwriting (Required)
- Strong verbal, written, interpersonal communication, and customer service skills (Required)
- Ability to interpret policies and procedures and communicate complex clinical topics effectively (Required)
Estimated Salary: $63,000-$110,000 per year.
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