(Archived) Stop Loss / Utilization Review RN (Remote, Contractor, Flex Hours)

Job Summary:

Amalgamated Medical Care Management, Inc. (AMCM) provides clinical and medical expertise for cost of care related to stop loss for AMCM’s affiliate company, Amalgamated Life Insurance Company (ALICO).

This position is responsible for focusing stop loss risk management activities on the centralized stop loss team and coordinating risk oversight with care delivery related areas of the company. Assures care is coordinated across the company and throughout the care delivery system for high risk members of groups with stop loss coverage underwritten by the company. Uses established guidelines to ensure appropriate levels of care and to plan transitions of care.

This position is part of a team of nurse reviewers that provide support to under writers and assist with AMCM’s affiliate company, Amalgamated Life Insurance Company. This position works closely with the Executive Director of Utilization and Case Management.

Essential Duties and Responsibilities:

• This position is responsible for focusing on AMCM’s stop loss risk management activities on the centralized stop loss team and coordinating risk oversight with care delivery related to ALICO.
• When applicable, assures care is coordinated across AMCM and throughout the care delivery system for high risk members of groups with stop loss coverage underwritten by the ALICO.
• Uses established guidelines to ensure appropriate levels of care and to plan transitions of care.
• When appropriate, works with the CM team and delivery functions of the AMCM to identify potential high risk patients in new business and renewal groups, and to assess patient's clinical need against established guidelines, ensuring care levels are medically necessary and appropriate.
• When appropriate, works with the CM team to ensure potential high risk claimants are engaged in care management protocols.
• Elicits support from sales and account management, brokers, consultants and group customers.
• Uses reporting and risk identification tools on medical and pharmacy claims to assess risk.
• Assists underwriting in evaluating risks in existing and potential stop loss groups.
• Assists in responding to inquiries from ALICO, sales and other partners for additional information on large claimants.
• Acts as a resource to sales and account management teams in communicating with stop loss management.
• Performs other duties as may be assigned by management

Education and/or Experience:

• Requires an ASN or BSN in nursing licensed in the state of residence.
• Requires a minimum of two (2) years of clinical experience.
• Requires minimum of three (3) years of experience in the health care delivery system/industry or health care payer experience.
• Prefers pending or obtained certification in case management or other applicable clinical specialties.

Knowledge and skills:

• Requires understanding of health and prescription costs.
• Requires understanding of health delivery systems and professionals.
• Requires understanding of disease life cycle, disease progression, expected health outcomes based on standard, accepted care management principles.
• Understanding of stop loss reporting tools and requirements preferred.
• Understanding of risk mitigation, high claimant detection, engagement and management preferred.
• Requires strong inter-personal skills with a demonstrated ability to work across divisions and with external stakeholders.
• Requires proficiency in the use of personal computers and in supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint, MS Project).

Physical Demands:

• Ability to work in a limited space.
• Lifting up to 25 lbs. on occasion.
• Ability to work from home in a HIPAA compliance home office environment.