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