[Hiring] Stop Loss Nurse @Imagine360

Role Description

Imagine360 is seeking a Stop Loss Nurse to join the team! The Stop Loss Nurse is responsible for identifying, monitoring, and managing high-cost and complex medical claims that may exceed stop-loss thresholds, supporting timely reporting, cost-containment strategies, and compliance with stop-loss policy requirements. This role focuses on early identification of large claimants, clinical review of high-cost drivers, and coordination with internal and external stakeholders, and support for timely carrier notification. The nurse collaborates with internal teams, TPAs, employers, and stop-loss carriers to manage large claims and minimize financial risk to ensure high quality and cost-effective care for members.

Position Location: 100% remote

• Case Identification & Review
  • Identify potential high-cost claims that may reach or exceed stop-loss thresholds through review of claims data, utilization trends, trigger diagnosis reports, and referral sources.
  • Review medical records, claims data, and treatment plans and utilization patterns to identify high-cost claims.
  • Track and monitor ongoing claims approaching stop-loss thresholds and escalate as appropriate for reporting and intervention.
• Clinical & Claim Evaluation
  • Review high cost and catastrophic medical claims to ensure policy compliance, and clinical appropriateness of services.
  • Evaluate complex cases and develop clinically informed summaries of current status, expected treatment trajectory, and projected future costs exposure for stop-loss reporting and underwriting support.
  • Analyze catastrophic and high acuity episodes of care to identify ongoing risk, cost drivers and opportunities for intervention.
  • Review potential claim notices, high-cost claimant reports, trigger diagnosis reports, and referrals from UM, CM, DM or brokers/clients to evaluate cost exposure and determine next steps.
• Cost Containment & Utilization Management
  • Implement cost-containment strategies such as redirection to in-network or high-quality, cost-effective providers.
  • Collaborate with case management to manage high-cost therapies.
  • Support development of improved processes for identifying and flagging high cost claimants.
• Stop Loss Coordination
  • Collaborate with stop-loss carriers to submit timely notifications, updates, and required documentation.
  • Prepare and manage large case reporting, including ongoing updates to stakeholders.
  • Ensure compliance with stop-loss policy requirements and deadlines.
• Data Analysis & Reporting
  • Maintain accurate documentation of case activities, outcomes, and cost savings.
  • Analyze claim trends, recurring high-cost drivers, and emerging patterns, and provide insights to leadership and clients.
  • Prepare recurring and adhoc reports on large claims and potential exposures.
• Compliance & Quality Assurance
  • Adhere to all regulatory requirements, HIPAA guidelines, and internal policies.
  • Participate in audits and quality improvement initiatives.
  • Maintain clinical documentation standards that support audit readiness, reporting accuracy and defensible case decision-making.

Qualifications

• A nursing degree from an accredited college, university, or school of nursing.
• 2+ years of clinical experience (e.g., acute care, ICU, oncology, or case management).
• 2+ years experience in case management, utilization review, or managed care.
• Strong knowledge of medical terminology, healthcare delivery systems, and insurance processes.

Requirements

• Preferred experience with stop-loss insurance, large claims, or self-funded health plans.
• Certification in Case Management (CCM) or similar.
• Experience with high-cost claims such as transplants, oncology, or specialty drugs.
• Familiarity with claims systems and healthcare analytics.

Skills and Abilities

• Strong clinical assessment and critical thinking skills.
• Excellent communication and interpersonal abilities.
• Ability to analyze complex data and make cost-effective care decisions.
• Negotiation and problem-solving skills.
• Strong organizational skills and attention to detail.
• Ability to work independently and collaboratively in a fast-paced environment.

Licenses or Certification

• Active, unrestricted Registered Nurse (RN) license from an accredited college, university, or school of nursing.
• Must maintain active, current, and unrestricted Registered Nurse license and CEUs as required by the State Board of Nursing.
• Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization.
• Must obtain Certified Case Manager (CCM) designation within 3 years of hire.

Benefits

• Multiple Health plan options.
• Company paid employee premiums for disability and life insurance.
• Parental Leave Policy.
• 20 days PTO to start / 10 Paid Holidays.
• Tuition reimbursement.
• 401k Company contribution.
• Company paid Short & Long term Disability plus Life Insurance.
• Professional development initiatives / continuous learning opportunities.
• Opportunities to participate in and support the company's diversity and inclusion initiatives.