RN Clinical Underwriter: Medical Risk & Cost Containment

EmblemHealth, Inc.; New York (NY); In loco; USD 68.000 - 119.000; Tempo pieno

Descrizione del lavoro

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.

Competenze

• 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.

Mansioni

• 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.

Conoscenze

RN

Medical underwriting

Medical risk management

ICD-10 coding

Regulatory knowledge

MS Office

Communication skills

Clinical knowledge

Formazione

Bachelor's Degree in Nursing

AHIP certification

Strumenti

MS Office

Descrizione del lavoro

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.