Clinical Underwriting Nurse

EmblemHealth, Inc.; New York (NY); On-site; USD 68,000 - 119,000; Full time

Job summary

EmblemHealth is seeking a Registered Nurse with 4+ years of underwriting or medical risk management experience to assess medical risk for identified claimants and project future costs for underwriting decisions.

Responsibilities include reviewing complex claim data, analyzing procedures and drug reports, and communicating results to care teams and vendors. The role requires strong clinical knowledge and the ability to work independently in a regulated environment.

Qualifications

• RN licensed professional with registered nurse credentials.
• Bachelor's degree in Nursing or related clinical field.
• 4-6+ years of professional relevant work experience is required.
• 4 years' experience in medical underwriting or medical risk management, clinical coding or AHIP certification is required.
• Three years' direct clinical experience, preferably in an acute care.
• Additional years of experience may be considered in lieu of educational requirements.
• Strong ability to work independently and manage multiple tasks.

Responsibilities

• Assess medical risk for identified claimants and project annual claim costs for underwriting.
• Review detailed claim reports and clinical information from various sources.
• Present clear medical review summaries and future projections to underwriting team.
• Communicate medical necessity review results to primary care teams and providers.
• Analyze codes (CPT/HCPCS/ICD-10) and drug reports to predict utilization needs.
• Provide clinical opinions to claims examiners and underwriters when requested.
• Consult with clients on high-cost claims and guide risk management strategies.
• Develop work plans, timelines, and goals for assigned tasks.
• Monitor regulatory changes to stay compliant with reporting requirements.

Skills

RN

Medical underwriting

Medical risk management

ICD-10 coding

Regulatory knowledge

MS Office

Communication skills

Clinical knowledge

Education

Bachelor's Degree in Nursing

AHIP certification

Tools

MS Office

Job description

Summary of Position

Assess medical risk for each identified claimant utilizing all available information and applying appropriate guidelines to meet the financial risk management goals of the company. Review detailed large claim reports and available clinical information from a variety of sources including trigger reports, detailed individual claim reports, pending and denied reports, case management reports, and utilization reports. Present and document a clear medical review summary with an analysis of the current clinical conditions and a future annual claim projection to underwriting team.

Principal Accountabilities

• Research rare/complicated medical conditions/treatment options using resources including the internet, nursing, clinical resource tools by state/network.
• Ensure timely and accurate communications of medical necessity review results to the original requester (e.g., primary care team, specialty providers, vendors) in compliance with regulatory and contractual requirements.
• Analyze medical procedures codes, medication J codes, and prescription drug reports to assist in predicting the future claim costs and clinical prognosis utilization needs.
• Make recommendations based on medical review summary; conduct necessary referrals to Clinical Cost Containment Services; partner with team(s) as needed to ensure care plan and approach are effective to support financial risk management and clinical cost containment based on the identified clinical needs and predicted prognosis.
• Provide clinical opinion from knowledge, experience and/or research to claims examiners and underwriters as requested or deemed appropriate.
• Consult with internal and external clients on high cost claims and successfully engage effective clinical risk management strategies.
• Plan and develop work plans, establish timelines, and set goals for assigned work.
• Utilize a comprehensive approach to risk mitigation within area of responsibility by monitoring regulatory changes to ensure on-going adherence to reporting requirements.
• Stay informed of current medical and drug trends and share information with team members.

Qualifications

• Registered Nurse (RN)
• Bachelor's Degree in Nursing or related clinical field
• 4 - 6+ years of professional relevant work experience (Required)
• 4 years' experience in medical underwriting or medical risk management, clinical coding or AHIP certification (Required)
• Three years' direct clinical experience, preferably in an acute care (Required)
• Additional years of experience/specialized training may be considered in lieu of educational requirements (Required)
• Ability to successfully work independently; organizational skills; ability to manage multiple tasks simultaneously (Required)
• Demonstrated analytical skills; ability to exercise sound judgment, initiative and discretion (Required)
• Proficient with MS Office (Word, Excel, Powerpoint, Outlook) (Required)
• Demonstrated ability to establish effective working relationships with coworkers and customers (Required)
• Knowledge of ICD 10 coding and medical terminology (Required)
• Knowledge of state and federal regulations related to underwriting (Required)
• Strong verbal, written, interpersonal communication and customer service skills (Required)
• Ability to interpret policies and procedures and communicate complex clinical topics effectively (Required)

Additional Information

• Hiring Range: $68,040-$118,800