Complex Claims Specialist - AMAP

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

• 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)