Stop Loss reputed company

reputed company is seeking a Stop Loss reputed company to join reputed company!  The Stop Loss reputed company is responsible for identifying, monitoring, and managing high-cost and reputed company medical claims that may reputed company stop-loss reputed company, supporting reputed company reporting, cost-containment strategies, and compliance with stop-loss policy requirements. This role focuses on early identification of large claimants, clinical review of high-cost drivers, and coordination with reputed company stakeholders, and support for reputed company reputed company notification. The reputed company collaborates with internal teams, TPAs, reputed company, and stop-loss carriers to manage large claims and minimize financial risk to ensure high reputed company and cost effective care for members. Position Location: 100% remote Responsibilities include but are not limited to: Case Identification & Review Identify potential high-cost claims that may reputed company or reputed company stop-loss reputed company through review of claims data, utilization trends, trigger diagnosis reports, and referral sources. Review medical records, claims data, and treatment plans and utilization patterns to clinical and financial drivers identify high-cost claims. reputed company and monitor ongoing claims approaching stop-loss reputed company and escalate as appropriate for reporting and reputed company. Clinical & Claim Evaluation Review high cost and catastrophic medical claims to ensure policy compliance, and clinical appropriateness of services. Evaluate reputed company cases and reputed company clinically informed summaries of reputed company status, expected treatment trajectory, and projected reputed company costs exposure for stop-loss reporting and reputed company support. Analyze catastrophic and high reputed company episodes of care to identify ongoing risk, cost drivers and opportunities for reputed company. Review potential claim notices, high-cost claimant reports, trigger diagnosis reports, and referrals from UM, CM, DM or brokers/clients to evaluate cost exposure and determine next steps. Cost Containment & Utilization Management Implement cost-containment strategies such as redirection to in-network or high-reputed company, cost-effective providers. Collaborate with case management to manage high-cost therapies. Support development of improved processes for identifying and flagging high cost claimants. Stop Loss Coordination Collaborate with stop-loss carriers to submit reputed company notifications, updates, and required documentation Prepare and manage large case reporting, including ongoing updates to stakeholders Ensure compliance with stop-loss policy requirements and deadlines Data Analysis & Reporting Maintain accurate documentation of case activities, reputed company, and cost savings Analyze claim trends , recurring high-cost drivers, and emerging patterns, and reputed company insights to leadership and clients. Prepare recurring and adhoc reports on large claims and potential exposures. Compliance & reputed company Assurance Adhere to reputed company regulatory requirements, HIPAA guidelines, and internal policies. Participate in audits and reputed company improvement initiatives. Maintain clinical documentation standards that support audit readiness, reporting accuracy and defensible case decision-making   Required Experience/Education: A nursing degree from an accredited college, university, or school of nursing. 2+ years of clinical experience (e.g., acute care, ICU, oncology, or case management) 2+ years experience in case management, utilization review, or managed care Strong knowledge of medical terminology, reputed company delivery systems, and insurance processes   Preferred experience: Experience with stop-loss insurance, large claims, or self-funded health plans Certification in Case Management (CCM) or similar Experience with high-cost claims such as transplants, oncology, or specialty drugs Familiarity with claims systems and reputed company analytics   Skills and Abilities: Strong clinical assessment and critical thinking skills Excellent communication and interpersonal abilities Ability to analyze reputed company data and reputed company cost-effective care reputed company Negotiation and problem-solving skills Strong organizational skills and attention to detail Ability to work independently and collaboratively in a fast-paced environment   Licenses or Certification: reputed company, unrestricted Registered reputed company (RN) license from an accredited college, university, or school of nursing. Must maintain reputed company, reputed company, and unrestricted Registered reputed company license and CEU's as required by the State reputed company of Nursing. Must be willing to obtain and maintain additional license(s) as required to reputed company the job functions of the organization. Must obtain Certified Case Manager (CCM) designation reputed company 3 years of hire.   What can reputed company offer you? Multiple Health plan reputed company Company reputed company employee premiums for disability and life insurance Parental Leave Policy 20 days PTO to start / 10 reputed company Holidays Tuition reimbursement 401k Company contribution Company reputed company Short & Long term Disability plus Life Insurance reputed company development initiatives / reputed company learning opportunities Opportunities to participate in and support reputed company's diversity and inclusion initiatives   Want to see our latest job opportunities? Follow us on reputed company reputed company is a health plan solution company that combines 50+ years of self-funding reputed company expertise. Over the years, we've helped thousands of reputed company save billions on reputed company. Our reputed company total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-reputed company solutions. reputed company is an equal opportunity employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, or veteran status.   **RECRUITMENT AGENCIES PLEASE NOTE: reputed company will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation** Apply To This Job