Director, Reinsurance Clinician

Position Overview

The Director, Reinsurance Clinician will assist the Large Claims Solutions and Underwriting Departments in recognizing and managing potential large claim medical exposures. This role will work with policyholders, third party administrators, BCBS plan medical management and outside vendors to manage medical and financial risk opportunities.

This position reports to the Director, Claims & Clinical.

Essential Elements

• Clinical Claim Review- conducts initial medical necessity review of high-risk medical claims, interact with plan medical management teams on high-cost claims to advise the Underwriting Department and Claims department of potential catastrophic utilization. Partner with outside specialty network vendors to identify potential areas for cost savings.
• Excess of Loss (XOL) Management- clinical review, audit and relationship management of XOL clients.
• Risk Management- create methods and models for anticipating loss activity in specialty reinsurance medical products, recommend reserving levels relating to large cases, accurately project costs of medical conditions, create reports on trends for product offerings, assist with tracking of risk on high-cost claimants by utilizing Risk Management database to document current claimant clinical status, cost containment activities, vendors, etc.
• Cost Management- assess and recommend effective claim cost containment and managed care vendors including preferred provider networks, alternative treatment strategies and delivery systems.
• Research and Development- identify relevant trends in new and emerging medical technologies through research of publications, networking in the health care delivery system, and attending relevant medical meetings, gain awareness of new diagnoses, treatments, costs and industry trends.

Requirements

Education and Certifications

• R.N. licensing required
• MBA preferred

Experience

• 5 years health insurance/reinsurance experience preferred with heavy emphasis on large case management preferred
• 3 years stop loss/ excess of loss experience preferred
• 3 years of experience in an ambulatory or hospital setting required
• Strong customer service and relationship management skills required
• Moderate excel skills preferred

Travel Required

• Travel up to 10% domestic, quarterly onsite visits to corporate headquarters

Competencies

BCS Core Competencies

Informing, Courage, Customer Service, Learning on the Fly, Action Oriented, Drive for Results