Clinical Risk Specialist RN

Captive Resources, LLC; Itasca (IL); On-site; USD 137,000 - 150,000; Full time

Job summary

Captive Resources, LLC is seeking a Clinical Risk Specialist RN to provide high quality case management and claims management consulting, including identification, assessment and projections of high-cost cases to assist in underwriting.

Qualifications include ASN/BSN licensure in the state, with at least two years of clinical and two years in stop loss/health payer experience. Occasional travel may be required.

Qualifications

• ASN or BSN in nursing licensed in the state of residence.
• At least two years of clinical experience.
• At least two years of stop loss or health payer experience.

Responsibilities

• Reviewing stop-loss cases, making recommendations on potential cost of care, including lasers recommendations.
• Use established guidelines when conducting stop-loss case reviews.
• Works with underwriting team to identify potential high-risk claimants in new business and renewal groups.
• Elicits support from sales and account management, and underwriting.
• Use reporting and risk identification tools on medical and pharmacy claims to assess risk.
• Assists in responding to inquiries from underwriting and sales for additional information on large claimants.
• Review of monthly TPA reporting on current business for reserving.
• Understanding of health and prescription costs.
• Understanding of health delivery systems and professionals.
• Understanding of disease life cycle, disease progression, expected health outcomes based on standard, accepted care management principles.
• Understanding of stop loss reporting tools and requirements preferred.
• Understanding of risk mitigation, high claimant detection, engagement and management preferred.
• Requires strong interpersonal skills with a demonstrated ability to work across divisions and with external stakeholders.
• Requires proficiency in the use of MS Office, AMS product suite, and ESL Office (Connexure/David Young).

Skills

Stop-loss case review

Risk identification

Interdepartmental collaboration

MS Office

AMS product suite

ESL Office (Connexure/David Young)

Education

ASN or BSN in nursing

Tools

MS Office

AMS product suite

ESL Office (Connexure/David Young)

Job description

Job Category: Health Solutions / Medical Stop Loss

Requisition Number: CLINI001368

• Posted : July 17, 2026
• Full-Time

Locations

• Hybrid - Corporate Office, 1100 Arlington Heights Rd, Itasca, IL 60143, USA
• Remote, 1100 N Arlington Heights Rd, Itasca, IL 60143, USA

Pay or shift range: $137,000 USD to $150,000 USD. The estimated range is the budgeted amount for this position. Final offers are based on various factors, including skill set, experience, location, qualifications and other job-related reasons. Our benefits include medical, dental, vision, Rx, 401(k), life and AD&D, short-term and long-term disability, and more. Please visit our website for more information.

Description

The Clinical Risk Specialist RN is responsible for providing high quality case management and claims management consulting, including identification, assessment and projections of high-cost cases to assist in the underwriting process.

ESSENTIAL EDUCATION AND EXPERIENCE: ASN or BSN in nursing licensed in the State of Residence; at least two (2) years of clinical experience, AND at least two (2) years of stop loss or health payer experience.

SKILLS/COMPETENCIES REQUIREMENTS:

• Reviewing stop-loss cases, making recommendations on potential cost of care, including lasers recommendations.
• Use established guidelines when conducting stop-loss case reviews.
• Works with underwriting team to identify potential high-risk claimants in new business and renewal groups.
• Elicits support from sales and account management, and underwriting.
• Use reporting and risk identification tools on medical and pharmacy claims to assess risk.
• Assists in responding to inquiries from underwriting and sales for additional information on large claimants.
• Review of monthly TPA reporting on current business for reserving.
• Understanding of health and prescription costs.
• Understanding of health delivery systems and professionals.
• Understanding of disease life cycle, disease progression, expected health outcomes based on standard, accepted care management principles.
• Understanding of stop loss reporting tools and requirements preferred.
• Understanding of risk mitigation, high claimant detection, engagement and management preferred.
• Requires strong interpersonal skills with a demonstrated ability to work across divisions and with external stakeholders.
• Requires proficiency in the use of MS Office, AMS product suite, and ESL Office (Connexure/David Young).

TRAVEL: Occasional travel may be required for meetings, conferences, or client visits. This includes compliance with all of the requirements of the localities and destinations, as well as transportation carrier requirements.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.