Symetra has an exciting opportunity to join our team as a Medical Risk Consultant! About the role 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. This person will be aligned to support business that is west coast based. What you will do Review policyholder data to identify claimants with catastrophic care needs and assess medical and claim information to calculate potential risk. Provide written claimant assessments within established timeframes to the Underwriters/RGM's for use when establishing rates for new and renewal business. Review potential stop loss claim notices to identify case management and cost containment opportunities to reduce potential excess loss claim expenses. 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. Maintain current claimant clinical status, cost containment activities and contact information in ESL. Act as a resource for internal and external customers: Identify and support training opportunities for Claims, Underwriting, Sales, and TPA when knowledge gaps are identified. Provide clinical opinion from knowledge, experience and/or research to claims examiners and underwriters as needed. Assess and recommend effective claim cost containment and managed care vendors including preferred provider networks in assigned geographical region. Identify geographical healthcare trends in assigned marketplace for potential solution implementation. Keep Underwriting and Sales appraised of any trends that pose risk. Represent Symetra at Industry Conferences attending educational sessions to gain awareness of new diagnoses, treatments, costs, and industry trends. Maintain CE hours to meet State RN Licensure and CCM (or Industry) certification renewal requirements. Author educational articles to provide industry updates to internal contacts. Project leadership and participation as needed. Your experience and skills Registered Nurse license required. Associate's Degree required. Bachelor's degree preferred. 4+ years clinical nurse experience and two or more years case management experience preferred. 2+ years' experience in health care or health insurance industry; stop loss or reinsurance preferred. Case Manager Certification (CCM) and Insurance industry education (LOMA, HIAA, ICA, etc.) preferred. Comfortable using a variety of resources to research diagnoses, treatments, and average costs. 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. Work Authorization Employer work visa sponsorship and support are not provided for this role. Applicants must be currently authorized to work in the United States at hire and must maintain authorization to work in the United States throughout their employment with our company.
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