[Remote] Clinical Risk Manager, C&F Stop Loss

Note: The job is a remote job and is open to candidates in USA. Crum & Forster is seeking a Clinical Risk Manager for its Accident & Health division’s C&F Stop Loss business. The role evaluates complex clinical and claims data to assess medical risk, support underwriting decisions, and identify cost-containment opportunities. It also partners with clients and stakeholders, ensures data quality, and provides clinical expertise, mentorship, and operational support.

Responsibilities

• Review and analyze all data and documentation within existing systems and that provided by Underwriting including but not limited to diagnoses, procedures, case management notes, treatment plans, and comorbid conditions to assess validity of data and clinical risk
• Identify clinical factors that may impact underwriting outcomes or financial exposure at a claimant and population health level for Underwriters to leverage in their rating of the group
• Exercise independent clinical judgment to synthesize complex medical information into clear risk conclusions that support sound underwriting decisions
• Support the development and implementation of clinical risk management strategies for high-cost, complex claims through strategic identification of cost-containment opportunities while reviewing all available data for MUW review
• Cross-refer to cost containment when appropriate and participate in cost containment work as requested
• Triage and prioritize requests for medical underwriting review based on business urgency, workload capacity, and alignment with underwriting and leadership priorities
• Act as a strategic partner to underwriting by applying evidence-based criteria and sound clinical judgment to evaluate complex clinical and claims data to identify, quantify, and advise on significant risks, directly influencing underwriting strategy and decisions
• Develop, maintain, and manage strong relationships with internal and external clients, Third-Party Administrators (TPAs), and vendors, championing exemplary customer service standards
• Consult with clients and teams on submitted data for MUW, program development, quality improvement, and claim issues
• Act as a point of contact for escalations and participate in calls with internal and external clients as needed
• Ensure accurate entry, validation, and analysis of medical underwriting data within the claims system, maintaining high standards of data integrity
• Perform accurate and thorough data scrubbing of reports for medical underwriting reviews, leveraging advanced skills in Excel and using AI tools and other available tools and resources
• Request needed medical and claim data, collect said data and create reports in collaboration with Digital Transformation and/or IT teams to streamline departmental processes
• Identify and resolve data gaps and discrepancies to ensure comprehensive data for cost containment interventions
• Maintain clear records to support transparency and defensibility of underwriting decisions as it relates to clinical evaluation
• Participate in quality assurance activities related to medical underwriting evaluations and engage in peer review and audit processes as requested
• Serve as a primary subject matter expert, articulating complex clinical conditions, pharmaceuticals, and risk structures to diverse audiences, including executive leadership
• Stay informed on emerging therapies, technologies, and medical conditions, disseminating key information to internal and external stakeholders
• Provide concise, detailed, and clear assessments, projections, and recommendations, effectively explaining complex scenarios to both technical and non-technical audiences
• Support and explore new methods and processes to increase efficiency and achieve individual and organizational goals
• Ensure compliance with all company policies, procedures, and service standards
• Document all activities and outcomes accurately and promptly, keeping management informed of progress and potential issues
• Maintain proficiency with all IT systems utilized by the Clinical Risk Management team

Skills

• 6-10 years clinical experience with a current unrestricted licensure as a health professional (Registered Nurse)
• 6+ years of experience required
• Bachelor's degree from an accredited university or equivalent experience required
• Strong PC skills including Excel, Word, Outlook
• Group medical, managed care, health insurance, stop loss or reinsurance experience required
• Strong knowledge of disease processes and treatment plans
• Analytical & Operational Excellence: Possesses expert analytical, investigative, troubleshooting, and problem-solving skills with the ability to interpret complex medical and risk reports
• Highly organized and adaptable, capable of independently managing multiple priorities with exceptional attention to detail in a fast-paced environment
• Communication & Relationship Management: Demonstrates excellent interpersonal, oral, and written communication skills, with a strong focus on customer satisfaction and building rapport
• Expert in negotiation, persuasion, and conflict resolution
• Professional Drive & Accountability: Exhibits a strong work ethic, personal accountability, and a commitment to producing high-quality, accurate work
• A proactive, quick learner dedicated to getting the job done well
• Collaboration, Leadership & Mentorship: Proven ability to work effectively both independently and collaboratively within a team, with demonstrated ability to lead work efforts, mentor and guide junior staff, and support training and onboarding of new employees
• Preferably in the reinsurance or insurance industry

Benefits

• This is a remote role.
• Flexible work arrangements.
• You may also have the opportunity to participate in discretionary equity (stock) based compensation and/or performance-based variable pay programs.
• Generous 401K employer match.
• Employee Stock Purchase plan with employer matching.
• Generous Paid Time Off.
• Excellent benefits that go beyond health, dental & vision.
• Wellness programs focus on your family’s complete wellness, including your physical and mental wellbeing.
• Tuition reimbursement, industry related certifications and professional training available to you.
• A dynamic, ambitious, fun and exciting work environment.
• A spirit of social responsibility, matching donation program, volunteer opportunities, and an employee driven corporate giving.

Company Overview

Company H1B Sponsorship