Clinical Stop Loss Nurse

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🌽 Illinois, Montana, +3 more states – Remote

🌽 Illinois – Remote 🦬 Montana – Remote 🌶️ New Mexico – Remote 🌪️ Oklahoma – Remote 🤠 Texas – Remote

💵 $84.4k - $152.3k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

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Health Care Service Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Health Care Service Corporation is an independent licensee of the Blue Cross Blue Shield Association, serving nearly 23 million people across the United States with a wide range of health benefit solutions. The company provides health coverage options for various groups, including employers, individuals, families, as well as Medicare and Medicaid plans. In addition to health insurance, HCSC offers services such as pharmacy solutions, life and dental insurance, and health data technology. With nearly a century of experience, HCSC is dedicated to improving access to quality care, enhancing health outcomes, and reducing costs while maintaining a deep commitment to its members and local communities.

📋 Description

• Review case management notes, large claims reports, and shock reporting for individuals and groups seeking stop loss insurance quotes and renewals • Work closely with internal claim, clinical, and case management teams • Develop ongoing care and cost projections • Communicate projections to underwriting to help evaluate potential risk and associated costs • Complete cost projections on new and renewal business within 24–48 hours of receipt • Document a clinical summary and estimated cost of care for each individual identified as at risk

🎯 Requirements

• Bachelor's degree in nursing is preferred • Current state licensure • At least 3–5 years of clinical experience • 2–4 years of experience with Stop Loss products and clinical programs • Strong analytical and problem-solving skills • Excellent organizational and time management skills • Ability to work independently with little supervision while handling numerous projects at once • Excellent written and verbal communication skills, especially with underwriting staff • Ability to complete cost projections on new and renewal business within 24–48 hours of receipt • Ability to document a clinical summary and estimated cost of care for each individual identified as at risk • Track record of highly accurate, detail-oriented work • Computer proficiency, strong typing skills, and Internet research skills • Clear understanding of Microsoft Word, Microsoft Office, and Excel • Preferred: clinical claims review and claims auditing experience • Preferred: experience managing complex or catastrophic health cases • Preferred: specialty clinical experience in intensive care medicine, orthopedic, NICU/pediatric, oncology, diabetic member management, or obstetric/maternity management • Preferred: working toward or completion of CCM/CCP/CDE/MCG certification or an advanced degree • Preferred: knowledge of Milliman Guidelines or similar clinical guidelines • Preferred: knowledge of medical management policies and procedures

🏖️ Benefits

• Curated development plans and professional development • Annual incentive bonus plan • Health and wellness benefits • 401(k) savings plan • Pension plan • Paid time off • Paid parental leave • Disability insurance • Supplemental life insurance • Employee assistance program • Paid holidays • Tuition reimbursement • Other incentives • Drug-free and smoke-free workplace • Reasonable accommodations during the application process