Overview
The Clinical Review Nurse supports the stop-loss underwriting team by evaluating medical records, high-cost claimants, and emerging risk indicators to inform pricing and risk decisions. This role combines clinical expertise with analytical review, helping carriers accurately assess severity, predictability, and potential future exposure while ensuring appropriate application of medical management best practices.
Key Responsibilities
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Review medical records, claim histories, precertification notes, and treatment plans to identify clinical risk factors and cost drivers.
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Provide clinical summaries and recommendations to underwriters regarding risk severity, prognosis, and potential future claim exposure.
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Evaluate large claimants and ongoing care cases (e.g., oncology, NICU, transplant, complex chronic conditions).
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Collaborate with underwriting, actuarial, claims, and case management teams to ensure consistent interpretation of medical risk.
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Identify inappropriate, duplicate, or excessive treatments and escalate when needed.
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Monitor trends in high-cost claim conditions and contribute insights to underwriting guidelines.
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Assist with claim audits, stop-loss renewals, and new business evaluations.
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Support vendor and care-management programs by aligning clinical risk with cost-containment strategies.
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Maintain accurate documentation and comply with HIPAA and regulatory requirements.
