[Hiring] Clinical Risk Manager @Crum & Forster

Role Description

This is a remote role.

The Senior Clinical Risk Manager role utilizes a high level of experience and advanced knowledge regarding nursing, complex medical conditions, risk, prognoses, treatment plans, and utilization of care. This senior-level position provides accurate current and next year cost projections and savings opportunities to C&F while independently troubleshooting complex clinical, claims, and data issues. The Senior Clinical Risk Manager also serves as a resource to the Clinical Risk Management team by leading work efforts, mentoring team members, and supporting the onboarding and training of new employees.

What you will do:

• Medical Risk Assessment & Clinical Evaluation:
  • Review and analyze all data and documentation within existing systems and that provided by Underwriting.
  • Identify clinical factors that may impact underwriting outcomes or financial exposure.
  • Exercise independent clinical judgment to synthesize complex medical information into clear risk conclusions.
  • Support the development and implementation of clinical risk management strategies.
  • Cross-refer to cost containment when appropriate and participate in cost containment work as requested.
• Strategic Underwriting Partnership:
  • Triage and prioritize requests for medical underwriting review.
  • Act as a strategic partner to underwriting by applying evidence-based criteria.
• Client & Stakeholder Management:
  • Develop, maintain, and manage strong relationships with internal and external clients.
  • Consult with clients and teams on submitted data for MUW, program development, quality improvement, and claim issues.
  • Act as a point of contact for escalations and participate in calls with internal and external clients as needed.
• Data Management, Reporting, & Quality Assurance:
  • Ensure accurate entry, validation, and analysis of medical underwriting data.
  • Perform accurate and thorough data scrubbing of reports for medical underwriting reviews.
  • Request needed medical and claim data, collect said data and create reports.
  • Identify and resolve data gaps and discrepancies.
  • Maintain clear records to support transparency and defensibility of underwriting decisions.
  • Participate in quality assurance activities related to medical underwriting evaluations.
• Subject Matter Expertise & Communication:
  • Serve as a primary subject matter expert, articulating complex clinical conditions.
  • Stay informed on emerging therapies, technologies, and medical conditions.
  • Provide concise, detailed, and clear assessments, projections, and recommendations.
• Operational Excellence & Compliance:
  • Support and explore new methods and processes to increase efficiency.
  • Ensure compliance with all company policies, procedures, and service standards.
  • Document all activities and outcomes accurately and promptly.
  • Maintain proficiency with all IT systems utilized by the Clinical Risk Management team.

Qualifications

• 6-10 years clinical experience with a current unrestricted licensure as a health professional (Registered Nurse) preferred.
• 6+ years of experience required, preferably in the reinsurance or insurance industry.
• Bachelor’s degree from an accredited university or equivalent experience required.
• Strong PC skills including Excel, Word, Outlook.
• Group medical, managed care, health insurance, stop loss or reinsurance experience required.
• Strong knowledge of disease processes and treatment plans.

Requirements

• Analytical & Operational Excellence: Expert analytical, investigative, troubleshooting, and problem-solving skills.
• Communication & Relationship Management: Excellent interpersonal, oral, and written communication skills.
• Professional Drive & Accountability: Strong work ethic, personal accountability, and commitment to high-quality work.
• Collaboration, Leadership & Mentorship: Proven ability to work effectively both independently and collaboratively.

Benefits

• Flexible work arrangements.
• Competitive compensation package.
• Generous 401K employer match.
• Employee Stock Purchase plan with employer matching.
• Generous Paid Time Off.
• Excellent benefits that go beyond health, dental & vision.
• Tuition reimbursement, industry-related certifications, and professional training available.
• A dynamic, ambitious, fun and exciting work environment.
• A spirit of social responsibility, matching donation program, volunteer opportunities.