Clinical Risk Manager / A&H - Remote
Crum & Forster
Eatontown, NJ, USA
1d ago

Summary :

Summary Our A&H division has a great opportunity for a Clinical Risk Manager to join our team while working remotely.

Insurance is all about managing risk and protecting people and businesses from the unpredictable. Founded in 1822, Crum & Forster is one of this country’s longest-

surviving insurance brands, with a proud history that is intertwined with the innovation and rapid growth of American business.

  • We offer a wide range of specialty and standard lines insurance products.
  • We are committed to the communities where we live and work.
  • We are most proud of our people more than 2,000 employees in over 50 locations nationwide.
  • We are an outstanding place to work, and we believe in promoting learning and development and helping our employees pursue a rewarding career path.

    Since 2000, the Accident & Health division of Crum & Forster has been offering a unique variety of insurance and reinsurance products nationwide.

    Our office is located in Eatontown, New Jersey and is home to a team of highly skilled and diverse individuals. Our in-house expertise includes underwriting, compliance, actuarial, premium and claims administration, loss control, case management and marketing.

    We place a strong focus on product development and creative distribution methods, along with excellent client service and support.

    Additionally we have a satellite office located in Edina, MN from which our Employer Stop Loss Division operates.

    Responsibilities : Responsibilities


  • Ensure effective risk management. Consult with internal and external clients on high cost claims and successfully engages 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 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
  • Prepare monthly cost savings reports
  • Will abide by departmental policies and procedures, including authority levels, to comply with C&F's risk management controls.
  • Requirements : Requirements


  • Requires 7-10 years clinical experience with a current unrestricted licensure as a health professional (Registered Nurse).
  • 5+ years of case / claim management experience.
  • Group medical, managed care, health insurance, stop loss or reinsurance experience.
  • Able to set goals and handle multiple tasks, clients, and projects simultaneously; Ability to appropriately balance priorities, deadlines and deliverables.
  • Able to quickly adapt to change, work under tight deadlines and stressful conditions.

  • Intermediate level of investigative, analytical and problem solving skills.
  • Expert negotiating, persuasion and conflict resolution skills.
  • Ability to work well within a team and actively participate in team projects.
  • Must have excellent oral, written and interpersonal communication skills. PC skills to include word processing and spreadsheets.
  • Intermediate typing skills


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