Note: The job is a remote job and is open to candidates in USA. Old Republic Accident & Health is a leading specialty insurer seeking an experienced Clinical Risk Manager to join their team. This role involves leveraging clinical expertise to analyze treatment planning and utilization of care, while collaborating with medical underwriting to evaluate risk and manage exposure related to complex medical claims.
Responsibilities
- Lead and perform clinical, claims, and cost analyses to assess appropriateness of care and associated costs in support of claims reimbursement activities
- Oversee and conduct medical risk assessments by reviewing and analyzing underwriting documentation to validate data and project medical risk
- Identify and proactively communicate clinical factors that may impact underwriting outcomes or financial exposure, partnering with Underwriters on rating and risk evaluation
- Design and implement clinical risk management strategies for complex, high-cost claims, including identification of cost-containment opportunities
- Apply advanced clinical expertise and evidence-based criteria to evaluate complex data sets and provide guidance on material risks influencing underwriting strategy
- Serve as a clinical subject matter expert and key partner in building and maintaining relationships with internal and external stakeholders, including MGUs, TPAs, captives, brokers, and vendor partners
- Maintain thought leadership by staying current on healthcare trends, clinical guidelines, emerging therapies, medical technologies, and high-cost conditions
- Review claims and clinical data to develop case reserve projections and provide recommendations
- Provide clinical consultation and guidance across all Accident & Health lines of business
- Drive operational efficiencies, support quality assurance initiatives, and contribute to audit readiness and execution
- Ensure full compliance with corporate policies, procedures, regulatory requirements, and service standards
Skills
- Bachelor's degree required
- Current licensure as a Registered Nurse with 7–10 years of clinical experience
- 5–7 years of experience in the insurance industry required, including stop-loss insurance or reinsurance
- Strong analytical, investigative, and problem-solving skills with the ability to interpret complex clinical and financial data
- Comprehensive knowledge of medical terminology, disease processes, treatment protocols, and healthcare industry trends
- Excellent verbal and written communication skills with the ability to collaborate effectively with various internal and external stakeholders
- Highly organized with exceptional attention to detail; strong work ethic and ability to work independently while managing multiple priorities in a fast-paced environment
- Proficiency with Microsoft Office applications (Word, Excel, Outlook) and underwriting systems or related tools (e.g., Connexure, UGAN)
- Willingness to travel to client sites, industry conferences, and other Old Republic locations as needed
- Experience with captive stop loss, group medical, managed care, ancillary benefits, or specialty risk
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