Senior Clinical Risk Consultant

We’re in this for the greater good at ParetoHealth. Our mission is collective greatness, nothing less will do. Our team is a single force united in the drive to transform employee health benefits.

The company was founded in 2011 to help small and medium-sized businesses fight the rising cost of employee health benefits. We blazed the trail with financing innovations that reduce the risks in self-insurance and deliver significant savings—and we continue to lead with a growing ecosystem of partners and world-class cost control solutions.

But success is measured by more than dollars alone and we measure ours by the good that comes from knowing that every client and all their employees can count on effective, affordable healthcare for years to come.

Please note that ParetoHealth does not provide employment visa sponsorship for this position. Candidates must be authorized to work in the United States without sponsorship both now or in the future.

Position Summary:

The Sr. Clinical Risk Consultant plays a critical role in supporting stop loss underwriting by providing clinical expertise, risk assessment, and cost projections for high-cost claimants and emerging risks. This role partners closely with underwriting to evaluate medical conditions, treatment plans, and potential financial exposure, enabling informed underwriting decision-making.

Key Responsibilities:

• Clinical Risk Assessment
• Review medical records, diagnoses, and treatment plans for individuals and groups with high-cost or complex conditions
• Assess severity, prognosis, and likely progression of illnesses or injuries
• Identify potential high-risk cases, including transplant, oncology, neonatal, and chronic conditions
• Cost Projection & Financial Modeling Support
• Develop evidence-based cost projections for ongoing and future treatment
• Evaluate treatment pathways, including standard of care and emerging therapies
• Estimate timing and magnitude of claims exposure for underwriting purposes
• Underwriting Collaboration
• Partner with underwriters to provide clinical insight on risk selection, pricing, and policy terms
• Support new business and renewal underwriting with case-specific analysis
• Assist in determining appropriate laser levels, exclusions, or coverage strategies
• Treatment & Utilization Review
• Analyze appropriateness of care, site of service, and utilization patterns
• Identify opportunities for cost containment or alternative treatment strategies
• Monitor large claims and ongoing cases for changes in risk or cost trajectory
• Data Interpretation & Reporting
• Translate complex clinical information into clear, actionable summaries for non-clinical stakeholders
• Document findings, assumptions, and rationale for cost projections
• Contribute to reporting on high-cost risks and emerging clinical trends
• Market & Clinical Knowledge
• Stay current on medical advancements, specialty drugs, gene therapies, and high-cost treatments
• Understand healthcare cost drivers and reimbursement trends impacting stop loss risk

Required Skills & Qualifications:

• Education & Licensure
• Active Registered Nurse (RN) license required
• Bachelor of Science in Nursing (BSN) preferred
• Experience
• 5+ years of clinical experience (e.g., ICU, oncology, case management, or utilization review)
• Experience in stop loss, health insurance, underwriting support, or large claims review strongly preferred
• Familiarity with high-cost conditions (e.g., transplants, cancer, NICU, specialty pharmacy)
• Skills & Competencies
• Strong analytical and critical thinking skills
• Ability to interpret medical records and translate into financial risk insights
• Knowledge of medical cost drivers and treatment protocols
• Excellent written and verbal communication skills
• Detail-oriented with the ability to manage multiple cases simultaneously
• Technical Skills
• Proficiency in Microsoft Office (Excel, Word, Outlook)
• Experience with underwriting platforms, or clinical review tools preferred

Preferred Qualifications:

• Experience with stop loss carriers, TPAs, or health plans