Head of Large Claims Medical Strategy
2 weeks ago
The Director of Clinical Solutions for Large Claims will play a pivotal role in supporting the Large Claims Solutions and Underwriting Departments by identifying and managing significant medical exposure risks. This position will engage with policyholders, third-party administrators, and medical management teams to navigate both medical and financial risk opportunities effectively.
This role reports directly to the Director of Claims & Clinical.
Key Responsibilities
- Clinical Claim Assessment: Perform initial reviews of high-risk medical claims, collaborating with medical management teams on costly claims to inform the Underwriting and Claims departments about potential catastrophic utilization. Partner with external specialty network vendors to pinpoint opportunities for cost savings.
- Excess of Loss (XOL) Oversight: Conduct clinical reviews, audits, and maintain relationships with XOL clients.
- Risk Assessment: Develop methodologies and models to predict loss activities in specialty reinsurance medical products, recommend reserving levels for large cases, accurately forecast medical condition costs, and generate reports on trends for product offerings. Assist in monitoring risk for high-cost claimants by utilizing a Risk Management database to document current clinical statuses, cost containment efforts, and vendor interactions.
- Cost Containment Strategies: Evaluate and recommend effective claim cost containment and managed care vendors, including preferred provider networks and alternative treatment strategies.
- Research and Innovation: Stay informed about emerging medical technologies by researching publications, networking within the healthcare delivery system, and attending relevant medical conferences. Gain insights into new diagnoses, treatments, costs, and industry trends.
Education and Certifications:
- R.N. licensing is mandatory.
- MBA is preferred.
- A minimum of 5 years in health insurance or reinsurance, with a strong focus on large case management.
- At least 3 years of experience in stop loss or excess of loss.
- 3 years of experience in an ambulatory or hospital environment is required.
- Exceptional customer service and relationship management skills are essential.
- Moderate proficiency in Excel is preferred.
- Up to 10% domestic travel, including quarterly visits to corporate headquarters.
BCS Core Competencies include Informing, Courage, Customer Service, Learning on the Fly, Action Oriented, and Drive for Results.
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