Senior Complex Claims Specialist — Health Plan Risk & Cost

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

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