Clinical Cost Containment RN

Company Details

 

Berkley Accident and Health is a risk management company that designs innovative solutions to address the unique challenges of each client. With our entrepreneurial culture and strong emphasis on analytics, we can help employers better manage their risk. We offer a broad range of products, including employer stop loss, benefit captives, provider stop loss, HMO reinsurance, and specialty accident. The key to Berkley’s success is our nimble approach to risk – our ability to quickly understand, think through, and devise a plan that addresses each client’s challenges, coupled with the strong backing of a Fortune 500 company. Our parent company, W. R. Berkley Corporation, is one of the largest and best managed property/casualty insurers in the United States.

 

This position can either be fully remote (if not within commutable distance to the office) or based in our Hamilton Square, NJ office which offers a hybrid work schedule with 4 days in the office; and 1 day remote where it makes sense to do so.

#LI-AV1  #LI-Remote

The company is an equal employment opportunity employer.

Responsibilities

As a Clinical Cost Containment RN, you will provide consulting services for internal and external clients and their delegated entities. You'll report to our AVP, Clinical Health Risk Management.  We'll trust you to promote a thorough understanding of current and anticipated clinical needs and expected claims costs while facilitating the use of unique solutions to ensure optimal care and claims outcomes. (The CCC RN will not interact directly with patients).  

 

You'll play an integral role in support of Berkley Accident and Health's vision to be recognized as the industry leader in risk management service. CCC RNs assure optimal clinical outcomes obtained at a cost commensurate with the level of medical services rendered while also promoting client satisfaction and retention.

 

We'll count on you to:

• Be responsible for the independent review of TPA trigger reports, 50% notice reports, BAH claim referrals or similar information identifying potential catastrophic and/or catastrophic diagnoses or cases of concern regarding potential cost savings opportunities. Actively record, act upon and follow-up on identified diagnoses/case of concern in attempts to manage clinical risk mitigation/costs.
• Identify and present future or impending diagnosis of concern with ability to develop, determine and recommend clinical risk mitigation course of action for both BAH and our Clients.
• When appropriate, independently collaborate with internal departments to attempt to obtain updated/additional clinical or financial information from the client (TPA, Policyholder, Broker).
• Initiate and collaborate with cost containment vendors in support of Policyholder optimal outcomes.
• Serve as subject matter reference for our company’s cost containment programs, including but not limited to in our interaction with TPAs, Claims, Sales, Underwriters, Client Representatives, and Brokers.
• Serve as a subject matter reference in analysis of transplant contracts and provide guidance to the TPA/Case Managers in the selection of the best transplant contract for their client.
• Clinical Data Analytics - expertise in appropriate modules of ESL Office (David Young) with ability to data mine /research and resolve DY data, creation of data reporting & data outcomes requiring decision making and presentation skills in order to explain and recommend clinical risk mitigation solutions to both internal and external clients.
• Clinical Benchmarking - utilizing BAH/Client data analytics platforms, identify and benchmark current clinical areas of opportunities & concerns within Client & Catastrophic layer.
• Responsible for independently understanding the nuances of each line of business and adjusting activities and interventions based on the uniqueness of each market segment.
• Support Cost Containment department through creation of educational clinical risk management material, meetings & presentations for both internal (Sales, Claims, UW, Program/CR management, etc.)  BAH staff as well as our Brokers/Clients.
• Other duties may be assigned.

Qualifications

What you need to have:

• Current unrestricted license as a Registered Nurse. 
• 5+ years of direct clinical experience in a hospital or acute care setting
• 3+ years of Group medical, managed care, first dollar health insurance, stop loss or reinsurance experience.
• Must have a solid understanding of disease management and standard of care
• Ability to set goals and manage multiple tasks, clients, and projects simultaneously; abili