**Company :**

HM Insurance Group

**Job Description :**

**JOB SUMMARY**

This job is responsible for analyzing clinical data to assess potential stop loss and managed care claim liability, utilizing Case Management oversight techniques to ensure front line case management and cost containment activities are occurring at the first dollar level. This role provides pre-sale and renewal support to underwriting in evaluating potential claims that impact the risk by providing claim dollar projections on high cost claimants. The incumbent communicates effectively with Third Party Administrators, CM/UM vendors, department staff, Rx Operations staff, and all levels of department management as well as coaches, consults, and mentors team members on moderate to complex clinical issues.

**ESSENTIAL RESPONSIBILITIES**

+ Analyze clinical data to assess potential stop loss and managed care claim liability and utilize Case Management oversight techniques to ensure front line case management and cost containment activities are occurring at the first dollar level. Claim projections on high dollar claimants are used during the underwriting process to determine risk which has a direct impact on the profitabiliy of the company.Review all triaged notices of potential claims and make assessments regarding potential claims.Communicate with TPA Case Managers and/or their contracted CM/UM vendors to ensure effective case/care management, of all potential and actual stop loss and managed care claims with the overall objective of cost management.Verify network status and work with TPA Case Managers and/or internal cost containment staff to obtain discounting on all out of network claims and to review/reduce all claims that include excessive charges.Document findings according to department guidelines for documentation.

+ Provide pre-sale and renewal support to underwriting in evaluating potential claims that impact the risk.Claim projections on high dollar claimants are used during the underwriting process to determine risk which has a direct impact on the profitabiliy of the company. Evaluate potential high dollar claims as it relates to risk assessment using a variety of research sources as well as experiential knowledge to project future costs based on diagnosis, age and co-morbidities.

+ Communicate effectively with Third Party Administrators, CM/UM vendors, department staff and all levels of department management.Build and relationships with TPA Case Managers and CM/UM vendors to ensure the exchange of clinical information between HMIG and the other party is occurring.Identify and articulate problems and/or issues to various staff members including all levels of department management.Participate in functional walk-throughs.

+ Coach, consult and mentor team members on moderate to complex clinical issues. Provide ad-hoc job training to include moderate to complex business/system functionality and review of desktop procedures and training material.Provide feedback on team members'performance and subject matter expertise for new trainees.

+ Promote a culture of performance excellence.Enhance skills through the quality improvement process.Participate in process and operational improvement initiatives.Build and maintain effective relationships throughout the department to advance performance excellence.

+ Other duties as assigned or requested.

**EXPERIENCE**

**Required**

+ 5 years with Any combination of clinical, case management, and/or disease/condition management experience, provider operations, and/or health insurance experience

**Preferred**

+ Experience in insurance industry with claim management

+ Experience with excess risk product and related claim management/cost containment techniques

+ Experience with self-funding, Third Party Administration, and Managed Care

**SKILLS**

+ Broad knowledge of disease processes

+ Understanding of healthcare costs and the broader healthcare service delivery system

+ Proficiency in MS Excel and strong analytic skills with ability to interpret, evaluate, and act on clinical and financial data, including analysis of statistical data

+ Excellent organizational, time management, and project management skills

**EDUCATION**

**Required**

+ High School / GED

**Preferred**

+ Bachelor's degree in Nursing

**LICENSES or CERTIFICATIONS**

**Required**

+ Registered Nurse

**Preferred**

+ Certified Case Manager (CCM)

**Language (Other than English):**

None

**Travel Requirement:**

0% - 25%

**PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS**

**Position Type**

Office- or Remote-based

Teaches / trains others

Occasionally

Travel from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

No

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

**_Disclaimer:_** _The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job._

**_Compliance Requirement_** _: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies._

_As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy._

_Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements._

**Pay Range Minimum:**

$57,700.00

**Pay Range Maximum:**

$106,700.00

_Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets._

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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Req ID: J253860