Clinical Claims Strategist for Complex Risk & Cost Reduction

Lockton Companies; Plano (TX); On-site; USD 75,000 - 110,000; Full time

Job summary

Lockton Companies seeks a Clinical Claims Specialist in our Specialty Practice to improve and reduce severity of complex claims and cost of risk for employer health plans. You will explain disease states and costs, provide cost-of-care estimates, and advise underwriting on medical care strategies.

You’ll review claims, monitor savings opportunities, and collaborate across teams to drive patient care improvements and cost reductions.

Qualifications

• RN license or Bachelor's in Healthcare Management or related field.
• Minimum of 5 years of clinical/risk management experience.
• Experience and/or knowledge of health insurance processes.
• CCM, NANCM, or other certification or designation is a plus.
• Working knowledge of quality and care management.
• Strong organizational skills with ability to handle multiple tasks in a fast-paced environment.
• Excellent oral and written communication skills.
• Ability to translate complex clinical topics to a non-clinical audience.
• Demonstrated advanced analytical and problem-solving skills.

Responsibilities

• Provide explanation of disease states and associated costs to internal and external stakeholders.
• Provide cost-of-care estimates used in risk assessment of stop loss underwriting.
• Consult with and advise underwriting on medical/clinical care approaches and standards of care.
• Serve as a resource regarding medical necessity and reimbursement of stop loss claims.
• Review claims and clinical documents to identify opportunities to improve member care and reduce costs.
• Collaborate with stakeholders to strategize clinical and cost-saving plans.
• Coordinate implementation of savings solutions with clients, TPAs, and carriers, and track savings performance.
• Manage task lists and open items and cases.
• Attend team clinical rounds to discuss cases and strategy solutions.

Skills

Clinical risk mgmt

Healthcare knowledge

Analytical skills

Communication skills

Microsoft Office

Education

RN license

Bachelor’s in Healthcare Management

Tools

Microsoft Word

PowerPoint

Outlook

Job description

Lockton Companies seeks a Clinical Claims Specialist in our Specialty Practice to improve and reduce severity of complex claims and cost of risk for employer health plans. You will explain disease states and costs, provide cost-of-care estimates, and advise underwriting on medical care strategies.

You’ll review claims, monitor savings opportunities, and collaborate across teams to drive patient care improvements and cost reductions.