Medical Risk Consultant

Job Description

In this role you will evaluate stop loss claimant details on incumbent and prospective business to evaluate potential medical and prescription treatment plan(s) and associated costs to provide estimated risk for Underwriting purposes.

Duties/Qualifications:

• Review policyholder data to provide financial assessment of risk which includes projecting the financial liability of claims while considering both the underlying medical condition/treatment plan and drug cost
• Utilize medical knowledge, professional resources, and clinical practice guidelines to assess treatment regimens, diagnosis descriptions and etiologies, and protocol instructions
• Develop a tracking system of claim cost projections regarding treatments, drugs, procedures, and their effectiveness in reducing stop loss claims costs
• Serve as a role model and coach through continuously educating claims and underwriting professionals on medical assessments
• Provide written claimant assessments within established timeframes to the Underwriters for use when establishing rates for new and renewal business
• Advise management and underwriters of potential claims involving significant risk as needed
• Work with Third Party Administrators (TPAs) and external Case Managers using medical and claims management resources to facilitate clinical and financial outcomes for claimants with complex and catastrophic medical conditions
• Act as a resource for internal and external customers on clinical opinion from knowledge, experience and/or research and identify geographical healthcare trends.
• Peer review and evaluate medical risk vendor

Skills/Abilities

• Registered Nurse license required
• Bachelor’s degree or equivalent combination of education and work experience
• Three years of clinical nurse experience and/or two or more years case management experience
• Three years of relevant experience, preferably in stop loss or reinsurance, a plus.
• Ability to use resources (e.g., systems, applications, and tools) to retrieve data and research diagnosis, treatments, and average cost.
• Strong proficiency with the Microsoft Office Suite especially Excel
• Works productively independently and as part of team
• Phenomenal customer service and interpersonal skills
• Great at relationship building with internal and external partners
• Adept at prioritization, organization, and time management
• Excellent written and verbal communication skills
• Thrives in a fast-paced environment
• High attention to detail

What We Offer:

We are proud to offer a competitive salary, generous and flexible PTO & paid holidays, 401(k) with match, exclusive discount programs, health & wellness programs, and more.

Benefits:

• Health insurance
• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health savings account
• Life insurance
• Vision insurance

About Evolution Risk Partners, LLC

Evolution Risk Partners (ERP) is a full service Managing General Underwriter that specializes in providing comprehensive, compelling, and leading-edge solutions for the Medical Stop Loss community. An organization built with the intent of redefining partnership through a shared vision of success, we endeavor to have a highly collaborative and engaged relationship with our broker, consultant, general agency and TPA partners.