Complex Claims Specialist - AMAP

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

At Lockton, we’re passionate about helping our people achieve their ultimate potential. Our people are curious, action-oriented and always striving to make ourselves and those around us better. We’re active listeners working to ensure understanding and problem solvers developing innovative solutions. If you can see yourself delivering excellent service to clients, giving back to our communities and being a part of our caring culture, you belong here.

Lockton is currently seeking a Clinical Claims Specialist within our Specialty Practice unit. The objective of this role is to improve and reduce the severity of complex and catastrophic claims, reduce the cost of risk while improving the health of our employer client’s employee health plan.

• Provide explanation of disease states and associated costs to internal and external stakeholders.
• Provide cost-of-care estimates used in the risk assessment of stop loss underwriting.
• Consult with and advise underwriting on medical/clinical care approaches, standards of care and research of data for new business and renewals.
• Serve as a resource regarding medical necessity issues, standards of care and analysis for the reimbursement of submitted stop loss claims.
• Review claims and clinical documents to identify and monitor opportunities to increase member quality of care and overall cost reduction.
• Collaborate with various key stake holders to strategize clinical and cost savings strategies and assist on execution of plan.
• Coordinate implementation of claims savings solutions with Lockton Client Service Teams, TPAs, and stop loss carriers including regular tracking to measure savings and plan performance.
• Manage and organize task lists and open items and cases.
• Attend team clinical rounds to discuss cases and strategy solutions.

Qualifications

Qualifications - External

Qualifications

• Licensure as a RN or Bachelor’s in Healthcare Management or related field.
• A 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 or experience in 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 and subjects to a non-clinical audience.
• Demonstrated advanced analytical and problem-solving skills.
• Working knowledge of Microsoft products (Word, Outlook, PowerPoint)

Equal Opportunity Statement

Lockton Companies is proud to provide everyone anequal opportunity to grow and advance. We are committed to an inclusive culture and environment where our people, clients and communities are treated with respect and dignity.

At Lockton, supporting diversity, equity and inclusion is ingrained in our values, and we believe that we are at our best when we fully embrace everyone. We strive to cultivate a caring culture that learnsfrom, celebrates and thrives because of ourbreadth of differences. As such, we recognize that recruiting, developing and retaining people with diverse backgrounds and experiences is vital and enabling our people to thrive personally and professionally is critical to our long‑term success.

About Lockton

Lockton is the largest privately held independent insurance brokerage in the world. Since 1966, our independence has allowed us to serve our clients, take care of our people and give back to our communities. As such, our 13,100+ Associates doing business in over 155 countries are empowered to do what’s right every day.

At Lockton, we believe in the power of all people. You belong at Lockton.

How We Will Support You

At Lockton, we empower you to be true to yourself in all that you do. Your success is our success, and we provide opportunities to help you grow and create a rewarding career path, however you envision it.

We are ready to meet you where you are today, and as your needs change over time. In addition to industry-leading health insurance, we offer additional options to support your overall health and wellbeing.

Any Employment Agency, person or entity that submits an unsolicited resume to this site does so with the understanding that the applicant's resume will become the property of Lockton Companies, Inc. Lockton Companies will have the right to hire that applicant at its discretion and without any fee owed to the submitting Employment Agency, person or entity. Employment Agencies, who have fee Agreements with Lockton Companies must submit applicants to the designated Lockton Companies Employment Coordinator to be eligible for placement fees.