Clinical Risk Manager, Medical Underwriting, C&F Stop Loss- Remote

Crum & Forster Company Overview

Since 2000, Crum & Forster’s Accident & Health division (A&H) has offered a diverse portfolio of specialty insurance and reinsurance products nationwide. We place a strong focus on product development and creative distribution methods, along with excellent client service and support.

 

In addition to our robust domestic portfolio, which spans both special risk and medical solutions, A&H works on an international basis through various partnerships. Our global capabilities provide our partners with even broader flexibility in underwriting solutions.

 

The qualities and capabilities of Crum & Forster Accident & Health demonstrate our philosophy of building meaningful, long-term partnerships and our dedication to providing alternative strategies in an ever-changing insurance market.

 

The A&H MBU takes a full-spectrum approach to designing and servicing a robust slate of products tailored to needs in Employer Stop Loss, Excess Medical, Life, and Ancillary and Supplemental benefits. Our diversified business model includes program partnerships as well as direct sales in Employer Stop Loss. At year-end 2023, the MBU recorded $741M in gross premium written.

Job Description

Information about the Role, Line of Business and Team:

The Clinical Risk Manager role utilizes a high level of experience and advanced knowledge regarding nursing, medical conditions, risk and prognoses as it relates to treatment plans and utilization of care. The Clinical Risk Manager provides accurate current and next year cost projections and savings opportunities to C&F.

 

What you will do:

1. Medical Risk Assessment & Clinical Evaluation

• Review and analyze all data and documentation within existing systems and that provided by Underwriting including but not limited to diagnoses, procedures, case management notes, treatment plans, and comorbid conditions to assess validity of data and clinical risk.
• Identify clinical factors that may impact underwriting outcomes or financial exposure at a claimant and population health level for Underwriters to leverage in their rating of the group.
• Exercise independent clinical judgment to synthesize complex medical information into clear risk conclusions that support sound underwriting decisions.
• Support the development and implementation of clinical risk management strategies for high-cost, complex claims through strategic identification of cost-containment opportunities while reviewing all available data for MUW review.
• Cross-refer to cost containment when appropriate and participate in cost containment work as requested.

2. Strategic Underwriting Partnership

• Triage and prioritize requests for medical underwriting review based on business urgency, workload capacity, and alignment with underwriting and leadership priorities

• Act as a strategic partner to underwriting by applying evidence-based criteria and sound clinical judgment to evaluate complex clinical and claims data to identify, quantify, and advise on significant risks, directly influencing underwriting strategy and decisions.

3. Client & Stakeholder Management

• Develop, maintain, and manage strong relationships with internal and external clients, Third-Party Administrators (TPAs), and vendors, championing exemplary customer service standards.
• Consult with clients and teams on submitted data for MUW, program development, quality improvement, and claim issues.
• Act as a point of contact for escalations and participate in calls with internal and external clients as needed.

4. Data Management, Reporting, & Quality Assurance

• Ensure accurate entry, validation, and analysis of medical underwriting data within the claims system, maintaining high standards of data integrity.
• Perform accurate and thorough data scrubbing of reports for medical underwriting reviews, leveraging advanced skills in Excel and using AI tools and other available tools and resources.
• Request needed medical and claim data, collect said data and create reports in collaboration with Digital Transformation and/or IT teams to streamline departmental processes.
• Identify and resolve data gaps and discrepancies to ensure comprehensive data for cost containment interventions.
• Maintain clear records to support transparency and defensibility of underwriting decisions as it relates to clinical evaluation.
• Participate in quality assurance activities related to medical underwriting evaluations and engage in peer review and audit processes as requested.

5. Subject Matter Expertise & Communication

• Serve as a primary subject matter expert, articulating