Complex Claims Specialist - AMAP

Lockton; Plano (TX); On-site; USD 75,000 - 115,000; Full time

Job summary

Lockton is seeking a Clinical Claims Specialist in Plano, TX, within our Specialty Practice unit. The role focuses on reducing severity of complex claims and lowering costs while improving health outcomes for employer plans.

You will explain disease states, estimate costs, and advise underwriting on clinical care approaches. Ideal candidates hold RN licensure or a Bachelor's in Healthcare Management with 5+ years of clinical/risk management experience, and strong communication and analytical

Qualifications

• RN licensure or Bachelor's in Healthcare Management.
• Minimum of 5 years of clinical/risk management experience.
• Experience with health insurance processes.
• CCM or NANCM certification is a plus.
• Strong organizational and time-management skills.
• Excellent verbal and written communication abilities.
• Ability to translate clinical topics to non-clinical audiences.
• Advanced analytical and problem-solving skills.
• Proficient with Microsoft Word, Outlook and PowerPoint.

Responsibilities

• Explain disease states and costs to internal and external stakeholders.
• Provide cost-of-care estimates for risk assessment of stop loss underwriting.
• Consult with underwriting on medical care approaches and data for new business/renewals.
• Advise on medical necessity, standards of care and reimbursement analysis for stop-loss claims.
• Review claims and clinical documents to identify opportunities to improve care and reduce costs.
• Collaborate with stakeholders to plan clinical and cost-saving strategies.
• Coordinate implementation of savings solutions with service teams, TPAs, and carriers.
• Organize task lists, open items, and cases; track progress.

Skills

Clinical risk management

Health insurance processes

Analytical skills

Communication skills

Project management

Education

RN licensure

Bachelor's in Healthcare Management

Tools

Microsoft Word

Outlook

PowerPoint

Job description

Your Responsibilities

Description - External

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 - External

• 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.
• Proven time management experience.
• 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)