RN Clinical Risk Specialist – Stop-Loss Underwriting

Virtue Health; United States; On-site; USD 120,000 - 180,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Life insurance

Disability insurance

401(k)

PTO

Job summary

Virtue Health is building a private Stop Loss Consortium to help mid-size employers self-fund health benefits with better risk control and transparency.

Your clinical assessments will influence stop-loss decisions and renewal strategies, intersecting claims, underwriting, and member outcomes. This role requires fast, accountable work and direct advocacy with carriers to minimize exposure for employers.

Qualifications

• 5+ years of direct clinical nursing in acute care (ICU, oncology, transplant, surgical, or complex chronic disease).
• Active RN license; compact state license preferred for multi-state remote work.
• 3+ years in case management, utilization review, or payer-side at a TPA, HMO, PPO, stop-loss carrier, or reinsurance firm.
• Working knowledge of stop-loss insurance, self-funded health plans, and TPA operations for underwriting discussions.
• CCM (Certified Case Manager) certification.

Responsibilities

• Review stop-loss claim notices and records to identify high-cost trajectories before excess loss occurs.
• Produce written clinical assessments translating prognosis into underwriting guidance and attachment point recommendations.
• Flag catastrophic exposure with reserve recommendations and clear risk narratives for leadership.
• Advocate with stop-loss carriers for laser reduction or removal at renewal using prognosis data and evidence.
• Partner with TPAs and external case managers as Virtue Health's clinical resource on complex cases.

Skills

RN license

Case management

Utilization review

CCM certification

Education

BSN or higher

Job description

Virtue Health is building a private Stop Loss Consortium to help mid-size employers self-fund health benefits with better risk control and transparency.

Your clinical assessments will influence stop-loss decisions and renewal strategies, intersecting claims, underwriting, and member outcomes. This role requires fast, accountable work and direct advocacy with carriers to minimize exposure for employers.