Job Description
Profile Summary:
Favorably impact Stop Loss risk profile through early identification of potential high cost patients.
Profile Description:
• Serves as a subject matter expert in the evaluation of medical information to clarify
diagnoses, evaluate the severity of medical conditions, and estimate the duration of
treatment and expected future costs.
• Researches clinical conditions and provides analytical review of the medical and/or
pharmacy data to formulate the history of events. Gathers and prepares preliminary clinical
and medical analysis based on information from historical claims utilization data.
• Provide support to rate development through timely and accurate clinical and medical
analysis to ascertain future risks and support the underwriting and risk management
decision
• Works collaboratively with the cost containment team ensure a proper hand off of potential
high cost patients. Pr...