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• Analyze “trigger reports” and high dollar claim referrals to identify potential financial exposure early in the claims process. Review the medical necessity and appropriateness of hospital claims, physician charges, specialty drug costs, usage and provide potential alternatives.
• Gather and analyze clinical information and medical records from all providers for cost containment and future cost determination by maintaining a close working relationship with plan administrators, vendors, third party payers, employers, re-insurers, and other social, psychological, and medical health care providers.
• Translate complex clinical information from medical reference books, patient medical records, charges, summary plan descriptions, and stop loss insurance benefits into clear, actionable reporting to evaluate liability/compensability and to make recommendations to non-clinical stakeholders.
• Compose clinical correspondence and communicate effectively with employees, employers (clients), TPA claims administrators, health care providers, claims and underwriting staff and executive management regarding current care and care alternatives.
• Apply clinical knowledge to make determinations of medical necessity. Troubleshoot complex clinical problems and practice independently without supervision of another licensed professional. Apply clinical expertise to make determinations of medical necessity and manage complex clinical issues while practicing independently without supervision from another licensed professional.
• Assess medical needs, care requirements and alternatives; monitor and follow up with the Plan Administrator, provider, etc. regarding the planning, coordination and progress of treatment; evaluate and suggest other treatment and facility alternatives as appropriate to facilitate quality, cost-effective medical care for high-risk individuals, trigger diagnoses and transplant losses.
• Provide cost containment by managing an inventory of Stop Loss claims (involving large case management, trigger diagnosis or transplant network losses), securing additional discounts from providers (either directly or through a preferred vendor), negotiating prices for medical services and supplies, negotiating settlements, developing transplant networks, evaluating losses, consulting with claims examiners about appropriateness of charges and educating clients and stop loss team about cost-effective alternatives.
• Work closely with Underwriting, Actuarial, Finance and other areas of the organization to provide clinical insights that inform policy pricing and reserve setting. Evaluate group claim information at the time of renewal and new business and provide underwriters with an estimated projection of expected claim dollars in the next policy period.
• Prepare monthly report on all large case management. Communicate daily regarding large cases to the appropriate individuals.
• Services telephone inquiries, internal and external, for status questions and for questions regarding claims. External/internal calls can and/or may be recorded and retained electronically specific to the department’s scope of services.
• Performs other job-related duties that may be occasionally assigned.

• Bachelor of Science in Nursing (BSN) or higher.
• Active RN license or APRN license.
• Five plus years of significant clinical experience, with backgrounds in acute or critical care being highly valued. Minimum of 5 years of clinical experience required; experience in acute or critical care strongly preferred.
• Broad range of HIPAA regulations required.
• Knowledge and hands-on experience with PC; Word, Excel required. Familiarity with Connexure ESL platform a plus.
• Demonstrated customer service skills.
• Demonstrated oral and written communication skills with all levels of personnel.
• Demonstrated ability in multi-tasking.

• Health/Dental/Vision
• Pension
• 401K
• Health Savings Account
• Life Insurance
• Paid Time Off

Candidate Advisory: To protect applicants from recruitment fraud, all correspondence from our Human Resources department will originate from email addresses ending in @Ullico.com. We will never ask candidates to provide sensitive personal or financial information through any other email domain.